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Glenohumeral Chondrolysis After Shoulder Arthroscopy With Thermal Capsulorrhaphy
Case Report
Glenohumeral Chondrolysis After Shoulder Arthroscopy With Thermal Capsulorrhaphy Christopher R. Good, M.D., Michael K. Shindle, M.D., Bryan T. Kelly, M.D., Tony Wanich, M.D., and Russell F. Warren, M.D.
Abstract: Glenohumeral chondrolysis is a rare but devastating complication that can occur after shoulder arthroscopy and thermal capsulorrhaphy. We retrospectively reviewed the medical records and imaging studies of 8 patients in whom glenohumeral chondrolysis developed after shoulder arthroscopy in which thermal energy was used. Of the 8 patients, 5 had previous thermal capsulorrhaphy for the diagnosis of instability. Two patients were diagnosed with instability with associated labral tears and underwent labral repair with thermal capsular shrinkage. One patient was diagnosed with a labral tear and underwent labral debridement with an extensive glenohumeral synovectomy via a thermal probe. No patients had evidence of chondral damage at their index arthroscopy, and none received postoperative pain pumps. In all patients, radiographic evidence of chondrolysis developed and repeat arthroscopy was performed to confirm the diagnosis. Open surgical stabilization has not been known to have this complication, and it is speculated that heating of the joint fluid at the time of arthroscopy from any source plays a role in cartilage death. Further studies are warranted to determine whether adequate outflow during shoulder arthroscopy where the fluid volume is relatively small will aid in avoiding complications associated with the use of heat sources. Key Words: Chondrolysis—Shoulder—Arthroscopy—Thermal capsulorrhaphy.
G
lenohumeral chondrolysis is a devastating complication that has recently been reported after shoulder arthroscopy. A recent review of the Englishlanguage literature found 5 published reports concerning glenohumeral chondrolysis after shoulder arthroscopy,1-5 with a total of 10 individual cases reported. Of these 10 cases, 5 were related to the use of a “color test”–assisted rotator cuff repair via gentian violet
From the Hospital for Special Surgery, New York, New York, U.S.A. Address correspondence and reprint requests to Michael K. Shindle, M.D., Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, U.S.A. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Good CR, Shindle MK, Kelly BT, Wanich T, Warren RF. Glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy. Arthroscopy 2007;23:797.e1797.e5 [doi:10.1016/j.arthro.2007.03.092]. 0749-8063/07/2307-6652$32.00/0 doi:10.1016/j.arthro.2007.03.092
dye, which has since been abandoned.2,4,5 Little is known about the pathophysiology of glenohumeral chondrolysis, but it may be related to the use of thermal energy during shoulder arthroscopy. Over the last decade, the use of thermal energy for the treatment of shoulder instability has become increasingly popular. During thermal capsulorrhaphy, tissues are heated to 65°C or higher to damage the heat-labile collagen cross-links, which cause the triple-helix arrangement of the collagen polypeptide chains to unwind and shorten.6-8 The treated tissue subsequently undergoes an inflammatory response with collagen fusion and a repair response with synovial hyperplasia and fibroblast proliferation.9 Thermal capsulorrhaphy has been associated with a number of complications including chondrolysis, axillary nerve damage, capsular ablation, recurrent instability, and adhesive capsulitis.9-13 There is conflicting evidence in the literature as to whether thermal
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 7 (July), 2007: pp 797.e1-797.e5
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C. R. GOOD ET AL.
energy can be safely used to smooth roughened articular surfaces without excessively destroying chondrocytes. Of the 10 previously published cases of chondrolysis, 4 were associated with previous arthroscopic thermal capsulorrhaphy.1,3 The following report presents an additional 8 cases of glenohumeral chondrolysis, all of which were associated with thermal capsulorrhaphy. After approval from our institutional review board, a retrospective chart review was performed on 8 patients referred to our institution for shoulder stiffness after arthroscopy. All 8 were operated on elsewhere and subsequently referred for the management of painful stiffness after arthroscopic shoulder stabilization. Medical records and imaging studies, including data from outside institutions, were reviewed for all patients in whom glenohumeral chondrolysis developed after shoulder arthroscopy in which a thermal device was used.
thermal capsulorrhaphy for the diagnosis of instability (Fig 1). Two patients were diagnosed with instability with an associated labral tear and underwent labral repair with thermal capsular shrinkage. One patient was diagnosed with a labral tear and underwent labral debridement with an extensive glenohumeral synovectomy via a thermal probe. No patients had evidence of chondral damage at their index arthroscopy. No patients received postoperative pain pumps. Chondrolysis onset was generally early and rapid, with repeat arthroscopy performed, on average, 8.2 months after the initial shoulder arthroscopy to confirm the diagnosis of chondrolysis and rule out infection. Patients required between 1 and 6 additional procedures after the onset of chondrolysis to manage their pain. DISCUSSION A recent search of the English-language literature revealed a total of 10 cases of glenohumeral chondrolysis after shoulder arthroscopy. Of these 10 cases, 5 occurred after the use of gentian violet dye injection into the glenohumeral joint during rotator cuff repair to help pinpoint the tear.2,4,5 This color test was associated with chondrolysis by 3 separate groups of authors, who concluded that the chondrolysis was
CASES A summary of the 8 cases is presented in Table 1. The mean age was 23 years (range, 15 to 39 years). There were 6 female and 2 male patients. Of the patients, 7 were right hand– dominant and 1 was left hand– dominant. Of the 8 patients, 5 had previous
TABLE 1.
Summary of Operative Details in Patients in Whom Glenohumeral Chondrolysis Developed After Shoulder Arthroscopy in Combination With a Thermal Device
Case Age No. (yr) Sex
Diagnosis
1
15
F
2
17
M
3
16
M
4
36
F
5
18
F
6
39
F
7
19
F
Instability/ labral tear Instability
8
18
F
Instability
Initial Procedure/Heat Source
Instability
Thermal capsulorrhaphy Instability/ Labral repair/ labral thermal tear capsulorrhaphy Labral tear Thermal labral and joint debridement Instability Thermal capsulorrhaphy Instability Laser capsular shrinkage Labral repair/ thermal coagulation Laser capsular shrinkage Thermal capsulorrhaphy
Mean Time to Definitive Treatment No. of (mo) Surgeries 5
23
3
25
2
4 3
5
7 4
Definitive Procedure
Humeral Cartilage Loss
Glenoid Cartilage Loss
Humeral head arthroplasty, 100% grade 4 100% grade 4 glenoid fascial allograft Humeral head arthroplasty, 100% grade 4 100% grade 4 glenoid fascial allograft
Pending Humeral head arthroplasty, (62 at last glenoid fascial allograft follow-up) recommended 63 Glenoid interpositional meniscal allograft 42 Scope debridement, humeral head mosaicplasty 9 Glenoid interpositional meniscal/Achilles allograft 78 Humeral head arthroplasty, glenoid fascial allograft 38 Total shoulder arthroplasty
50% grade 2
100% grade 4
50% grade 2
75% grade 4 (posterior) 50% grade 3
50% grade 4 (anterior/ posterior) 90% grade 4
70% grade 4
100% grade 4 100% grade 4 100% grade 4 100% grade 4
GLENOHUMERAL CHONDROLYSIS
797.e3
FIGURE 1. Plain radiographs reveal marked degenerative changes in the glenohumeral joint in an 18-year-old male athlete 23 months after his initial shoulder arthroscopy in which thermal capsulorrhaphy was performed.
caused by the gentian dye and warned against the future use of the color-test technique. Animal studies subsequently confirmed the potential harmful effects of gentian violet dye on chondrocytes, and this technique has been abandoned. Of the remaining 5 reported cases of chondrolysis after shoulder arthroscopy, 4 involved the use of a thermal device during the procedure.1,3 Petty et al.3 reported on 3 cases of glenohumeral chondrolysis after shoulder arthroscopy, 2 of which involved the use of radiofrequency (RF) energy within the glenohumeral joint. In 1 patient with recurrent subluxation, glenohumeral chondrolysis developed within 8 months after resection of the coracoacromial ligament and modified subacromial decompression with extensive synovectomy by use of RF ablation. Follow-up arthroscopy at 8 months confirmed the complete loss of glenoid articular cartilage with intact humeral head cartilage and marginal osteophytes. Another patient with multidirectional instability underwent shoulder arthroscopy, rotator cuff debridement, and thermal capsular shrinkage via a monopolar device. This patient complained of stiffness and persistent pain postoperatively and was subsequently seen at another institution. The results of the infection workup were negative, and follow-up radiographs revealed glenohumeral joint space narrowing. Repeat arthroscopy 18 months after the index procedure found that the glenoid was denuded of articular cartilage with patches of sclerotic bone noted. The humeral head also showed areas of cartilage fibrillation and fissuring with areas of denuded
cartilage. With an increasing number of reports involving complications, the initial wave of enthusiasm for thermal capsulorrhaphy has subsided.14 The final patient reported by Petty et al.3 underwent shoulder arthroscopy with subacromial decompression and undersurface rotator cuff debridement for the diagnosis of impingement and partial rotator cuff tear. The use of a thermal device was not documented; however, an intra-articular pain pump was inserted at the conclusion of the procedure. This patient was noted to have normal articular cartilage at the index procedure but continued to complain of pain, and repeat arthroscopy 6 months later revealed severe glenohumeral arthritis, with complete loss of glenoid cartilage and significant loss of humeral head cartilage. The results of the infection workup were again negative, including cultures and pathology, which were examined at the second arthroscopy. The presence of the pain pump in this case is interesting because the use of intra-articular pain pumps has recently been associated with cartilage loss as a result of toxic levels of local anesthetic15; however, this issue was not formally addressed. Levine et al.1 subsequently published a report of 2 additional cases of glenohumeral chondrolysis, both after shoulder arthroscopy with thermal capsulorrhaphy to treat shoulder instability. The first patient was a 19-year-old man who underwent thermal capsulorrhaphy with the “zebra striping” technique, during which normal strips of capsular tissue are left between areas of thermal shrinkage. A monopolar device was
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C. R. GOOD ET AL.
used for this procedure, and chondral surfaces were normal at the time of arthroscopy. The patient did well postoperatively and initially returned to competitive sport; however, his pain returned and persisted despite 6 months of physical therapy. Magnetic resonance imaging evaluation revealed complete destruction of the joint space, and the patient subsequently elected to undergo humeral head resurfacing with meniscal allografting on the glenoid side. Another patient, a 20year-old man, underwent arthroscopic labral repair and thermal capsulorrhaphy via a monopolar device for recurrent anterior instability. Chondral surfaces were found to be normal at the initial procedure, and the patient did well initially. Six months postoperatively, he began to complain of pain, and he underwent repeat arthroscopy 1 year after the index procedure. At that time, complete loss of glenoid cartilage and loss of 75% of humeral cartilage were noted. The patient was treated with arthroscopic debridement at that time but continued to complain of pain and was subsequently referred to another institution for evaluation. He was eventually treated with modified total shoulder replacement with a Copeland resurfacing humeral arthroplasty and a lateral meniscal allograft glenoid resurfacing procedure. The use of thermal energy for the treatment of shoulder instability is a relatively new technique and has been associated with a number of potential complications.13 Glenohumeral chondrolysis is a rare but potentially incapacitating complication after thermal capsulorrhaphy that has recently come to our attention. Little is known about the pathophysiology or natural history of this disease; however, recent studies have focused on the joint fluid temperatures during the use of a thermal device and the potential adverse effects of increased joint temperature on chondrocytes. Turner et al.16 and Kaplan and Uribe17 reported on the use of bipolar RF energy on articular cartilage surfaces and found no evidence of chondrocyte death. Both groups concluded that RF energy appeared safe for use on articular cartilage. Lu et al.18 subsequently reported contrasting results showing that bipolar RF energy was responsible for chondrocyte death after chondroplasty and even showed full-thickness cartilage loss after the procedure. In another study Edwards et al.19 further compared thermal chondroplasty using both monopolar and bipolar RF energy devices. They found that both types of devices were able to effectively smooth out roughened articular cartilage; however, monopolar RF energy caused less chondrocyte death than bipolar RF energy.
The actual fluid temperatures in the glenohumeral joint during thermal capsulorrhaphy are not yet known, however; Lu et al.20 recently examined the effects of thermal capsulorrhaphy in a simulated shoulder environment. They used a custom-built 25-mL chamber to simulate the glenohumeral joint and tested 3 separate RF energy systems to evaluate the effect on arthroscopic fluid temperature. They showed an increase in fluid temperatures during the use of a thermal device, with the highest increases occurring with continuous thermal treatment and no active flow of arthroscopic fluid. They concluded that using flow and intermittent rather than continuous thermal energy during thermal capsular shrinkage may lower joint fluid temperatures and prevent heated joint fluid from killing articular cartilage. Our study is the largest report to date of glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy, which further strengthens the association between the development of this condition and the use of thermal energy. Though rare, chondrolysis is a devastating complication that affects young active individuals and causes significant morbidity. In this case series patients underwent between 1 and 7 additional surgeries as a result of this complication, and all required an open surgical procedure. In addition, 4 patients underwent partial or total shoulder arthroplasty. To better understand this phenomenon, further studies are warranted. There is a need to investigate the temperatures that occur within the shoulder joint during the use of thermal devices to determine the threshold temperature at which damage to chondrocytes will occur. In addition, the recent increase in the use of thermal devices during arthroscopy of the ankle, hip, wrist, and elbow joints necessitates the study of this potential complication in these joints as well, particularly when the volume in some of these joints is relatively small, allowing rapid temperature change with the loss of outflow.
REFERENCES 1. Levine WN, Clark AM Jr, D’Alessandro DF, Yamaguchi K. Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability. A report of two cases. J Bone Joint Surg Am 2005;87:616-621. 2. Nakagawa Y, Ueo T, Miki T, Kotani H, Onishi E, Nakamura T. Glenohumeral osteoarthritis following a “color test” during rotator cuff repair. A case report and a review of the literature. Bull Hosp Jt Dis 1998;57:216-218. 3. Petty DH, Jazrawi LM, Estrada LS, Andrews JR. Glenohumeral chondrolysis after shoulder arthroscopy: Case reports
GLENOHUMERAL CHONDROLYSIS
4. 5.
6. 7.
8. 9. 10.
11. 12.
and review of the literature. Am J Sports Med 2004;32:509515. Shibata Y, Midorikawa K, Koga T, Honjo N, Naito M. Chondrolysis of the glenohumeral joint following a color test using gentian violet. Int Orthop 2001;25:401-403. Tamai K, Higashi A, Cho S, Yamaguchi T. Chondrolysis of the shoulder following a “color test”–assisted rotator cuff repair—A report of 2 cases. Acta Orthop Scand 1997;68:401402. Hayashi K, Thabit G III, Massa KL, et al. The effect of thermal heating on the length and histologic properties of the glenohumeral joint capsule. Am J Sports Med 1997;25:107-112. Naseef GS III, Foster TE, Trauner K, Solhpour S, Anderson RR, Zarins B. The thermal properties of bovine joint capsule. The basic science of laser- and radiofrequency-induced capsular shrinkage. Am J Sports Med 1997;25:670-674. Wall MS, Deng XH, Torzilli PA, Doty SB, O’Brien SJ, Warren RF. Thermal modification of collagen. J Shoulder Elbow Surg 1999;8:339-344. Abrams JS. Thermal capsulorrhaphy for instability of the shoulder: Concerns and applications of the heat probe. Instr Course Lect 2001;50:29-36. Fanton G. Thermally-assisted arthroscopic stabilization of the shoulder joint. In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott-Raven, 1999; 329-343. Gryler EC, Greis PE, Burks RT, West J. Axillary nerve temperatures during radiofrequency capsulorrhaphy of the shoulder. Arthroscopy 2001;17:567-572. McCarty EC, Warren RF, Deng XH, Craig EV, Potter H. Temperature along the axillary nerve during radiofrequency-
13. 14. 15.
16. 17. 18.
19.
20.
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induced thermal capsular shrinkage. Am J Sports Med 2004; 32:909-914. Sperling JW, Anderson K, McCarty EC, Warren RF. Complications of thermal capsulorrhaphy. Instr Course Lect 2001;50: 37-41. Levine WN, Bigliani LU, Ahmad CS. Thermal capsulorrhaphy. Orthopedics 2004;27:823-826. Gomoll AH, Kang RW, Williams JM, Bach BR, Cole BJ. Chondrolysis after continuous intra-articular bupivacaine infusion: An experimental model investigating chondrotoxicity in the rabbit shoulder. Arthroscopy 2006;22:813-819. Turner AS, Tippett JW, Powers BE, Dewell RD, Mallinckrodt CH. Radiofrequency (electrosurgical) ablation of articular cartilage: A study in sheep. Arthroscopy 1998;14:585-591. Kaplan L, Uribe JW. The acute effects of radiofrequency energy in articular cartilage: An in vitro study. Arthroscopy 2000;16:2-5. Lu Y, Edwards RB III, Nho S, Cole BJ, Markel MD. Lavage solution temperature influences depth of chondrocyte death and surface contouring during thermal chondroplasty with temperature-controlled monopolar radiofrequency energy. Am J Sports Med 2002;30:667-673. Edwards RB III, Lu Y, Nho S, Cole BJ, Markel MD. Thermal chondroplasty of chondromalacic human cartilage. An ex vivo comparison of bipolar and monopolar radiofrequency devices. Am J Sports Med 2002;30:90-97. Lu Y, Bogdanske J, Lopez M, Cole BJ, Markel MD. Effect of simulated shoulder thermal capsulorrhaphy using radiofrequency energy on glenohumeral fluid temperature. Arthroscopy 2005;21:592-596.
Glenohumeral Chondrolysis After Shoulder Arthroscopy With Thermal Capsulorrhaphy Christopher R. Good, M.D., Michael K. Shindle, M.D., Bryan T. Kelly, M.D., Tony Wanich, M.D., and Russell F. Warren, M.D.
Abstract: Glenohumeral chondrolysis is a rare but devastating complication that can occur after shoulder arthroscopy and thermal capsulorrhaphy. We retrospectively reviewed the medical records and imaging studies of 8 patients in whom glenohumeral chondrolysis developed after shoulder arthroscopy in which thermal energy was used. Of the 8 patients, 5 had previous thermal capsulorrhaphy for the diagnosis of instability. Two patients were diagnosed with instability with associated labral tears and underwent labral repair with thermal capsular shrinkage. One patient was diagnosed with a labral tear and underwent labral debridement with an extensive glenohumeral synovectomy via a thermal probe. No patients had evidence of chondral damage at their index arthroscopy, and none received postoperative pain pumps. In all patients, radiographic evidence of chondrolysis developed and repeat arthroscopy was performed to confirm the diagnosis. Open surgical stabilization has not been known to have this complication, and it is speculated that heating of the joint fluid at the time of arthroscopy from any source plays a role in cartilage death. Further studies are warranted to determine whether adequate outflow during shoulder arthroscopy where the fluid volume is relatively small will aid in avoiding complications associated with the use of heat sources. Key Words: Chondrolysis—Shoulder—Arthroscopy—Thermal capsulorrhaphy.
G
lenohumeral chondrolysis is a devastating complication that has recently been reported after shoulder arthroscopy. A recent review of the Englishlanguage literature found 5 published reports concerning glenohumeral chondrolysis after shoulder arthroscopy,1-5 with a total of 10 individual cases reported. Of these 10 cases, 5 were related to the use of a “color test”–assisted rotator cuff repair via gentian violet
From the Hospital for Special Surgery, New York, New York, U.S.A. Address correspondence and reprint requests to Michael K. Shindle, M.D., Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, U.S.A. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Good CR, Shindle MK, Kelly BT, Wanich T, Warren RF. Glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy. Arthroscopy 2007;23:797.e1797.e5 [doi:10.1016/j.arthro.2007.03.092]. 0749-8063/07/2307-6652$32.00/0 doi:10.1016/j.arthro.2007.03.092
dye, which has since been abandoned.2,4,5 Little is known about the pathophysiology of glenohumeral chondrolysis, but it may be related to the use of thermal energy during shoulder arthroscopy. Over the last decade, the use of thermal energy for the treatment of shoulder instability has become increasingly popular. During thermal capsulorrhaphy, tissues are heated to 65°C or higher to damage the heat-labile collagen cross-links, which cause the triple-helix arrangement of the collagen polypeptide chains to unwind and shorten.6-8 The treated tissue subsequently undergoes an inflammatory response with collagen fusion and a repair response with synovial hyperplasia and fibroblast proliferation.9 Thermal capsulorrhaphy has been associated with a number of complications including chondrolysis, axillary nerve damage, capsular ablation, recurrent instability, and adhesive capsulitis.9-13 There is conflicting evidence in the literature as to whether thermal
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 7 (July), 2007: pp 797.e1-797.e5
797.e1
797.e2
C. R. GOOD ET AL.
energy can be safely used to smooth roughened articular surfaces without excessively destroying chondrocytes. Of the 10 previously published cases of chondrolysis, 4 were associated with previous arthroscopic thermal capsulorrhaphy.1,3 The following report presents an additional 8 cases of glenohumeral chondrolysis, all of which were associated with thermal capsulorrhaphy. After approval from our institutional review board, a retrospective chart review was performed on 8 patients referred to our institution for shoulder stiffness after arthroscopy. All 8 were operated on elsewhere and subsequently referred for the management of painful stiffness after arthroscopic shoulder stabilization. Medical records and imaging studies, including data from outside institutions, were reviewed for all patients in whom glenohumeral chondrolysis developed after shoulder arthroscopy in which a thermal device was used.
thermal capsulorrhaphy for the diagnosis of instability (Fig 1). Two patients were diagnosed with instability with an associated labral tear and underwent labral repair with thermal capsular shrinkage. One patient was diagnosed with a labral tear and underwent labral debridement with an extensive glenohumeral synovectomy via a thermal probe. No patients had evidence of chondral damage at their index arthroscopy. No patients received postoperative pain pumps. Chondrolysis onset was generally early and rapid, with repeat arthroscopy performed, on average, 8.2 months after the initial shoulder arthroscopy to confirm the diagnosis of chondrolysis and rule out infection. Patients required between 1 and 6 additional procedures after the onset of chondrolysis to manage their pain. DISCUSSION A recent search of the English-language literature revealed a total of 10 cases of glenohumeral chondrolysis after shoulder arthroscopy. Of these 10 cases, 5 occurred after the use of gentian violet dye injection into the glenohumeral joint during rotator cuff repair to help pinpoint the tear.2,4,5 This color test was associated with chondrolysis by 3 separate groups of authors, who concluded that the chondrolysis was
CASES A summary of the 8 cases is presented in Table 1. The mean age was 23 years (range, 15 to 39 years). There were 6 female and 2 male patients. Of the patients, 7 were right hand– dominant and 1 was left hand– dominant. Of the 8 patients, 5 had previous
TABLE 1.
Summary of Operative Details in Patients in Whom Glenohumeral Chondrolysis Developed After Shoulder Arthroscopy in Combination With a Thermal Device
Case Age No. (yr) Sex
Diagnosis
1
15
F
2
17
M
3
16
M
4
36
F
5
18
F
6
39
F
7
19
F
Instability/ labral tear Instability
8
18
F
Instability
Initial Procedure/Heat Source
Instability
Thermal capsulorrhaphy Instability/ Labral repair/ labral thermal tear capsulorrhaphy Labral tear Thermal labral and joint debridement Instability Thermal capsulorrhaphy Instability Laser capsular shrinkage Labral repair/ thermal coagulation Laser capsular shrinkage Thermal capsulorrhaphy
Mean Time to Definitive Treatment No. of (mo) Surgeries 5
23
3
25
2
4 3
5
7 4
Definitive Procedure
Humeral Cartilage Loss
Glenoid Cartilage Loss
Humeral head arthroplasty, 100% grade 4 100% grade 4 glenoid fascial allograft Humeral head arthroplasty, 100% grade 4 100% grade 4 glenoid fascial allograft
Pending Humeral head arthroplasty, (62 at last glenoid fascial allograft follow-up) recommended 63 Glenoid interpositional meniscal allograft 42 Scope debridement, humeral head mosaicplasty 9 Glenoid interpositional meniscal/Achilles allograft 78 Humeral head arthroplasty, glenoid fascial allograft 38 Total shoulder arthroplasty
50% grade 2
100% grade 4
50% grade 2
75% grade 4 (posterior) 50% grade 3
50% grade 4 (anterior/ posterior) 90% grade 4
70% grade 4
100% grade 4 100% grade 4 100% grade 4 100% grade 4
GLENOHUMERAL CHONDROLYSIS
797.e3
FIGURE 1. Plain radiographs reveal marked degenerative changes in the glenohumeral joint in an 18-year-old male athlete 23 months after his initial shoulder arthroscopy in which thermal capsulorrhaphy was performed.
caused by the gentian dye and warned against the future use of the color-test technique. Animal studies subsequently confirmed the potential harmful effects of gentian violet dye on chondrocytes, and this technique has been abandoned. Of the remaining 5 reported cases of chondrolysis after shoulder arthroscopy, 4 involved the use of a thermal device during the procedure.1,3 Petty et al.3 reported on 3 cases of glenohumeral chondrolysis after shoulder arthroscopy, 2 of which involved the use of radiofrequency (RF) energy within the glenohumeral joint. In 1 patient with recurrent subluxation, glenohumeral chondrolysis developed within 8 months after resection of the coracoacromial ligament and modified subacromial decompression with extensive synovectomy by use of RF ablation. Follow-up arthroscopy at 8 months confirmed the complete loss of glenoid articular cartilage with intact humeral head cartilage and marginal osteophytes. Another patient with multidirectional instability underwent shoulder arthroscopy, rotator cuff debridement, and thermal capsular shrinkage via a monopolar device. This patient complained of stiffness and persistent pain postoperatively and was subsequently seen at another institution. The results of the infection workup were negative, and follow-up radiographs revealed glenohumeral joint space narrowing. Repeat arthroscopy 18 months after the index procedure found that the glenoid was denuded of articular cartilage with patches of sclerotic bone noted. The humeral head also showed areas of cartilage fibrillation and fissuring with areas of denuded
cartilage. With an increasing number of reports involving complications, the initial wave of enthusiasm for thermal capsulorrhaphy has subsided.14 The final patient reported by Petty et al.3 underwent shoulder arthroscopy with subacromial decompression and undersurface rotator cuff debridement for the diagnosis of impingement and partial rotator cuff tear. The use of a thermal device was not documented; however, an intra-articular pain pump was inserted at the conclusion of the procedure. This patient was noted to have normal articular cartilage at the index procedure but continued to complain of pain, and repeat arthroscopy 6 months later revealed severe glenohumeral arthritis, with complete loss of glenoid cartilage and significant loss of humeral head cartilage. The results of the infection workup were again negative, including cultures and pathology, which were examined at the second arthroscopy. The presence of the pain pump in this case is interesting because the use of intra-articular pain pumps has recently been associated with cartilage loss as a result of toxic levels of local anesthetic15; however, this issue was not formally addressed. Levine et al.1 subsequently published a report of 2 additional cases of glenohumeral chondrolysis, both after shoulder arthroscopy with thermal capsulorrhaphy to treat shoulder instability. The first patient was a 19-year-old man who underwent thermal capsulorrhaphy with the “zebra striping” technique, during which normal strips of capsular tissue are left between areas of thermal shrinkage. A monopolar device was
797.e4
C. R. GOOD ET AL.
used for this procedure, and chondral surfaces were normal at the time of arthroscopy. The patient did well postoperatively and initially returned to competitive sport; however, his pain returned and persisted despite 6 months of physical therapy. Magnetic resonance imaging evaluation revealed complete destruction of the joint space, and the patient subsequently elected to undergo humeral head resurfacing with meniscal allografting on the glenoid side. Another patient, a 20year-old man, underwent arthroscopic labral repair and thermal capsulorrhaphy via a monopolar device for recurrent anterior instability. Chondral surfaces were found to be normal at the initial procedure, and the patient did well initially. Six months postoperatively, he began to complain of pain, and he underwent repeat arthroscopy 1 year after the index procedure. At that time, complete loss of glenoid cartilage and loss of 75% of humeral cartilage were noted. The patient was treated with arthroscopic debridement at that time but continued to complain of pain and was subsequently referred to another institution for evaluation. He was eventually treated with modified total shoulder replacement with a Copeland resurfacing humeral arthroplasty and a lateral meniscal allograft glenoid resurfacing procedure. The use of thermal energy for the treatment of shoulder instability is a relatively new technique and has been associated with a number of potential complications.13 Glenohumeral chondrolysis is a rare but potentially incapacitating complication after thermal capsulorrhaphy that has recently come to our attention. Little is known about the pathophysiology or natural history of this disease; however, recent studies have focused on the joint fluid temperatures during the use of a thermal device and the potential adverse effects of increased joint temperature on chondrocytes. Turner et al.16 and Kaplan and Uribe17 reported on the use of bipolar RF energy on articular cartilage surfaces and found no evidence of chondrocyte death. Both groups concluded that RF energy appeared safe for use on articular cartilage. Lu et al.18 subsequently reported contrasting results showing that bipolar RF energy was responsible for chondrocyte death after chondroplasty and even showed full-thickness cartilage loss after the procedure. In another study Edwards et al.19 further compared thermal chondroplasty using both monopolar and bipolar RF energy devices. They found that both types of devices were able to effectively smooth out roughened articular cartilage; however, monopolar RF energy caused less chondrocyte death than bipolar RF energy.
The actual fluid temperatures in the glenohumeral joint during thermal capsulorrhaphy are not yet known, however; Lu et al.20 recently examined the effects of thermal capsulorrhaphy in a simulated shoulder environment. They used a custom-built 25-mL chamber to simulate the glenohumeral joint and tested 3 separate RF energy systems to evaluate the effect on arthroscopic fluid temperature. They showed an increase in fluid temperatures during the use of a thermal device, with the highest increases occurring with continuous thermal treatment and no active flow of arthroscopic fluid. They concluded that using flow and intermittent rather than continuous thermal energy during thermal capsular shrinkage may lower joint fluid temperatures and prevent heated joint fluid from killing articular cartilage. Our study is the largest report to date of glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy, which further strengthens the association between the development of this condition and the use of thermal energy. Though rare, chondrolysis is a devastating complication that affects young active individuals and causes significant morbidity. In this case series patients underwent between 1 and 7 additional surgeries as a result of this complication, and all required an open surgical procedure. In addition, 4 patients underwent partial or total shoulder arthroplasty. To better understand this phenomenon, further studies are warranted. There is a need to investigate the temperatures that occur within the shoulder joint during the use of thermal devices to determine the threshold temperature at which damage to chondrocytes will occur. In addition, the recent increase in the use of thermal devices during arthroscopy of the ankle, hip, wrist, and elbow joints necessitates the study of this potential complication in these joints as well, particularly when the volume in some of these joints is relatively small, allowing rapid temperature change with the loss of outflow.
REFERENCES 1. Levine WN, Clark AM Jr, D’Alessandro DF, Yamaguchi K. Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability. A report of two cases. J Bone Joint Surg Am 2005;87:616-621. 2. Nakagawa Y, Ueo T, Miki T, Kotani H, Onishi E, Nakamura T. Glenohumeral osteoarthritis following a “color test” during rotator cuff repair. A case report and a review of the literature. Bull Hosp Jt Dis 1998;57:216-218. 3. Petty DH, Jazrawi LM, Estrada LS, Andrews JR. Glenohumeral chondrolysis after shoulder arthroscopy: Case reports
GLENOHUMERAL CHONDROLYSIS
4. 5.
6. 7.
8. 9. 10.
11. 12.
and review of the literature. Am J Sports Med 2004;32:509515. Shibata Y, Midorikawa K, Koga T, Honjo N, Naito M. Chondrolysis of the glenohumeral joint following a color test using gentian violet. Int Orthop 2001;25:401-403. Tamai K, Higashi A, Cho S, Yamaguchi T. Chondrolysis of the shoulder following a “color test”–assisted rotator cuff repair—A report of 2 cases. Acta Orthop Scand 1997;68:401402. Hayashi K, Thabit G III, Massa KL, et al. The effect of thermal heating on the length and histologic properties of the glenohumeral joint capsule. Am J Sports Med 1997;25:107-112. Naseef GS III, Foster TE, Trauner K, Solhpour S, Anderson RR, Zarins B. The thermal properties of bovine joint capsule. The basic science of laser- and radiofrequency-induced capsular shrinkage. Am J Sports Med 1997;25:670-674. Wall MS, Deng XH, Torzilli PA, Doty SB, O’Brien SJ, Warren RF. Thermal modification of collagen. J Shoulder Elbow Surg 1999;8:339-344. Abrams JS. Thermal capsulorrhaphy for instability of the shoulder: Concerns and applications of the heat probe. Instr Course Lect 2001;50:29-36. Fanton G. Thermally-assisted arthroscopic stabilization of the shoulder joint. In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott-Raven, 1999; 329-343. Gryler EC, Greis PE, Burks RT, West J. Axillary nerve temperatures during radiofrequency capsulorrhaphy of the shoulder. Arthroscopy 2001;17:567-572. McCarty EC, Warren RF, Deng XH, Craig EV, Potter H. Temperature along the axillary nerve during radiofrequency-
13. 14. 15.
16. 17. 18.
19.
20.
797.e5
induced thermal capsular shrinkage. Am J Sports Med 2004; 32:909-914. Sperling JW, Anderson K, McCarty EC, Warren RF. Complications of thermal capsulorrhaphy. Instr Course Lect 2001;50: 37-41. Levine WN, Bigliani LU, Ahmad CS. Thermal capsulorrhaphy. Orthopedics 2004;27:823-826. Gomoll AH, Kang RW, Williams JM, Bach BR, Cole BJ. Chondrolysis after continuous intra-articular bupivacaine infusion: An experimental model investigating chondrotoxicity in the rabbit shoulder. Arthroscopy 2006;22:813-819. Turner AS, Tippett JW, Powers BE, Dewell RD, Mallinckrodt CH. Radiofrequency (electrosurgical) ablation of articular cartilage: A study in sheep. Arthroscopy 1998;14:585-591. Kaplan L, Uribe JW. The acute effects of radiofrequency energy in articular cartilage: An in vitro study. Arthroscopy 2000;16:2-5. Lu Y, Edwards RB III, Nho S, Cole BJ, Markel MD. Lavage solution temperature influences depth of chondrocyte death and surface contouring during thermal chondroplasty with temperature-controlled monopolar radiofrequency energy. Am J Sports Med 2002;30:667-673. Edwards RB III, Lu Y, Nho S, Cole BJ, Markel MD. Thermal chondroplasty of chondromalacic human cartilage. An ex vivo comparison of bipolar and monopolar radiofrequency devices. Am J Sports Med 2002;30:90-97. Lu Y, Bogdanske J, Lopez M, Cole BJ, Markel MD. Effect of simulated shoulder thermal capsulorrhaphy using radiofrequency energy on glenohumeral fluid temperature. Arthroscopy 2005;21:592-596.