Chondral defects of the glenohumeral joint: Long-term outcome after microfracturing of the shoulder

Surgical treatment options for articular cartilage defects of the glenohumeral joint: A systematic review

Background

Many joint-preserving surgical interventions for cartilage defects of the knee have been adapted for use in the shoulder; however, there still exists no clear consensus for treatment. Thus, the purpose of this systematic review was to evaluate the outcomes of different interventions in patients with focal chondral lesions of the glenohumeral joint.

Methods

A literature search was conducted using PubMed, Embase, and Medline. Patients who underwent a joint-preserving surgical procedure to treat a focal chondral defect of the glenoid, humeral head or both were included. Patients treated for diffuse cartilage defects or with shoulder arthroplasty were excluded.

Results

Ten studies were included, with follow-up data available for 194 shoulders. Eight joint-preserving procedures were evaluated, with microfracture being the most common. One study evaluating microfracture reported significant improvements in patient-reported outcomes at short-term and long-term follow-up compared to preoperative scores. Across all studies, 32 patients underwent subsequent shoulder surgery, with 22 being arthroplasties.

Conclusions

We found improvements in patient-reported and functional outcomes across all studies. Although joint-preserving procedures have shown reasonable outcomes for focal chondral defects of the glenohumeral joint, long-term outcomes remain unknown, and the progression of osteoarthritis remains a concern. Higher quality evidence is required to make definitive recommendations.

Level of Evidence

IV.

Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty

BACKGROUND

The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty.

METHODS

Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management.

RESULTS

A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n = 70; 59.3%) followed by review or expert opinion articles (n = 35; 29.7%). Most references were of level IV evidence (n = 60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty.

CONCLUSION

The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.

Long-term clinical and radiological outcomes following arthroscopic microfracture of the glenohumeral joint for chondral defects

Background

The primary aim of this study was to evaluate mid- and long-term outcomes following microfracture in patients with glenohumeral chondral lesions.

Methods

This prospective cohort study assessed patients with shoulder pain who were treated with arthroscopic microfracture for full-thickness chondral lesions of the glenohumeral joint. Outcomes included the Simple Shoulder Test at baseline, mid-term (approximately 1 year) and long-term (approximately 10 years), and the Oxford Shoulder Score, shoulder pain (0-10 numerical scale) and radiological assessment using a modified Samilson & Prieto score at long-term follow-up. Data were analyzed with paired t-tests and Wilcoxon's signed rank tests, which were considered significant if P < .05.

Results

Twenty-five patients with a mean age of 52.7 ± 12.1 were enrolled. The mean Simple Shoulder Test score improved from baseline to 1 year (6.7 ± 2.5 to 11.0 ± 1.4, P < .001), which was maintained at long-term follow-up (10.3 ± 2.1, P < .001). Additionally, at long-term follow-up, Oxford Shoulder Score and Verbal Pain Score scores were 43 ± 4.8 and 1.1 ± 1.5, respectively while median modified Samilson & Prieto scores increased from 1 preoperatively to 2 at 10 years (P < .001).

Conclusion

Patients undergoing microfracture for full-thickness chondral lesions of the glenohumeral joint reported substantial improvements in shoulder pain and function at 1 and 10 years, despite progressive radiological degeneration.

Simultaneous Arthroscopic Rotator Cuff Repair and Glenoid Microfracture in Active-Duty Military Patients Younger Than 50 Years: Outcomes at Midterm Follow-up

Background

While concomitant full-thickness rotator cuff tears and glenoid osteochondral defects are relatively uncommon in younger patients, military patients represent a unique opportunity to study this challenging injury pattern.

Purpose/Hypothesis

To compare the outcomes of young, active-duty military patients who underwent isolated arthroscopic rotator cuff repair (ARCR) with those who underwent ARCR plus concurrent glenoid microfracture (ARCR+Mfx). It was hypothesized that ARCR+Mfx would produce significant improvements in patient-reported outcome measures.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a retrospective analysis of consecutive active-duty military patients from a single base who underwent ARCR for full-thickness rotator cuff tears between January 2012 and December 2020. All patients were <50 years and had minimum 2-year follow-up data. Patients who underwent ARCR+Mfx were compared with those who underwent isolated ARCR based on the visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) shoulder score, and range of motion.

Results

A total of 88 patients met the inclusion criteria for this study: 28 underwent ARCR+Mfx and 60 underwent isolated ARCR. The mean final follow-up was 74.11 ± 33.57 months for the ARCR+Mfx group and 72.87 ± 11.46 months for the ARCR group (P = .80). There were no differences in baseline patient characteristics or preoperative outcome scores between groups. Postoperatively, both groups experienced statistically significant improvements in all outcome scores (P < .0001 for all). However, the ARCR+Mfx group had significantly worse VAS pain (1.89 ± 2.22 vs 1.03 ± 1.70; P = .05), SANE (85.46 ± 12.99 vs 91.93 ± 12.26; P = .03), and ASES (86.25 ± 14.14 vs 92.85 ± 12.57; P = .03) scores. At the final follow-up, 20 (71.43%) patients in the ARCR+Mfx group and 53 (88.33%) patients in the ARCR group were able to remain on unrestricted active-duty military service (P = .05).

Conclusion

Concomitant ARCR+Mfx led to statistically and clinically significant improvements in patient-reported outcome measures at the midterm follow-up. However, patients who underwent ARCR+Mfx had significantly worse outcomes and were less likely to return to active-duty military service than those who underwent isolated ARCR. The study findings suggest that ARCR+Mfx may be a reasonable option for young, active patients who are not candidates for arthroplasty.

Articular Cartilage Defects of the Glenohumeral Joint: A Systematic Review of Treatment Options and Outcomes

OBJECTIVE

To report radiographic and magnetic resonance imaging findings, patient-reported outcomes, and complications and/or reoperations following nonarthroplasty surgical intervention for focal glenohumeral cartilage defects.

DESIGN

A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Patients were included if they possessed a chondral defect of the humeral head, glenoid, or both, which had been treated with a joint preserving nonarthroplasty procedure. Risk of bias assessment was performed using the Methodological Index for Non-Randomized Studies scoring system. Study demographics, surgical technique, imaging findings, patient-reported outcomes, complications, failures, and reoperations were collected.

RESULTS

Fourteen studies with 98 patients (100 shoulders) met the inclusion criteria. Patient ages ranged from 7 to 74 years. The nonarthroplasty surgical techniques utilized included microfracture (67 shoulders), osteochondral transplantation (28 shoulders), chondrocyte transplantation (4 shoulders), and internal fixation (1 shoulder). The rates of radiographic union and progression of osteoarthritis ranged between 90% to 100% and 57% to 100%, respectively. Visual analog scores ranged from 0 to 1.9 at final follow-up. Mean postoperative ASES (American Shoulder and Elbow Surgeons) shoulder scores ranged from 75.8-100. Mean postoperative CSS (Constant Shoulder Score) scores ranged from 83.3-94. Mean postoperative SSV (Subjective Shoulder Value) ranged from 70% to 99%. Failure and reoperation rates ranged between 0% to 35% and 0% to 30%, respectively, with the most common reoperation being conversion to prosthetic arthroplasty.

CONCLUSIONS

In this systematic review, nonarthroplasty surgical techniques demonstrated acceptable rates of radiographic healing, improved patient reported outcomes, minimal complications, and low rates of failure or reoperation. Joint preserving techniques are likely viable options to prolong function of the native shoulder and provide short- to midterm pain relief in young and highly active patients.

LEVEL OF EVIDENCE

Level IV.

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Shoulder: An Orthoregeneration Network (ON) Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFβ), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.

Outcomes of rotator cuff repair with concurrent microfracture of focal glenohumeral osteoarthritis

BACKGROUND

The benefit of rotator cuff repair (RCR) in patients with concurrent osteoarthritic changes remains unclear. RCR has the theoretical potential to increase the compressive force across the glenohumeral joint, further exacerbating osteoarthritis pain. The purpose of this study is to investigate pain relief and patient-reported outcomes of patients undergoing simultaneous RCR and microfracture of focal glenohumeral osteoarthritis.

METHODS

Thirty-four patients undergoing simultaneous RCR and microfracture were retrospectively reviewed at a minimum 1-year follow-up. Patient demographics, preoperative range of motion, functional outcomes (visual analog scale [VAS], Single Assessment Numeric Evaluation [SANE], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], and Simple Shoulder Test [SST]), and operative metrics were recorded. The patients were then contacted to obtain postoperative functional outcome scores (VAS, SANE, ASES, and SST).

RESULTS

Twenty-seven patients (11 male/16 female [79%]) were evaluated at a mean follow-up of 25.8 months (range, 12-46). The average age at surgery was 64.9 years (range, 56-78). Chronic tears were more common than acute tears (57.7% vs. 42.3%). The majority of patients had a full rotator cuff tear (89%) involving a mean 1.7 ± 0.8 tendons (range, 1-3). Eighty-eight percent of the humeral lesions were Outerbridge 4 compared with 84% on the glenoid. The mean estimated involvement between the 2 groups with 38.4% ± 18.4% of the humeral head involved and 34.6% ± 18.4% of the glenoid involved. PRO scores improved postoperatively with a reduction in mean VAS (6.6-2.0, P < .01), SANE (33.8-79.8, P < .01), ASES (38.0-80.9, P < .01), and SST (3.07-9.70, P < .01) scores. Cumulatively, only 52% (14/27) of the patients improved, however, by the MCID for all collected PROs.

CONCLUSIONS

Our results demonstrate modest improvements in postoperative pain and functional scores at a minimum of 1-year follow-up in a cohort of patients who have undergone RCR and glenohumeral microfracture. In cases of small focal lesions of full-thickness cartilage loss, RCR with microfracture is a reasonable treatment option; however, patients should be counseled on expectations accordingly.

Assessment of Safe Cartilage Harvesting Quantity in the Shoulder: A Cadaveric Study

Purpose

To evaluate the volume and yield of morselized cartilage that can be harvested from the shoulder for immediate reimplantation and repair.

Methods

A standard arthroscopic approach was used to harvest non–load-bearing cartilage from 5 cadaveric shoulder specimens. Cartilage was separated from the humerus, grasped, added to the cartilage particulator, and morselized to form a cartilage paste. The volume of reclaimed cartilage was measured and compared with average humeral and glenoid defects.

Results

The total yield of cartilage paste following tissue processing that was obtained from the 5 glenohumeral joints ranged from 1.0 mL to 2.4 mL with a mean volume of 1.9 ± 0.5 mL, yielding a theoretical 18.6 cm² ± 5.2 cm² of coverage with a 1-mm monolayer. Previously reported mean glenoid defect size ranges from 1.12 cm² to 2.73 cm², while the mean humeral defect size ranges from 4.22 cm² to 6.00 cm².

Conclusions

This study validated that through a single-stage surgical and processing technique it is possible to obtain a sufficient volume for re-implantable autologous morselized cartilage graft to address most glenohumeral articular cartilage defects.

Clinical Relevance

Chondrocyte grafts have been shown to be effective in cartilage repair. A single-site, single-staged procedure that uses a patient’s autologous shoulder cartilage from the same joint has the potential to reduce morbidity associated with multiple surgical sites, multistaged procedures, or nonautologous tissue in shoulder surgery.

Does the Presence of Chondral Lesions Negatively Affect Patient-Determined Outcomes After Arthroscopic Rotator Cuff Repair?

Background:

There are limited data available to guide patients to their prognosis when glenohumeral chondral lesions are found during arthroscopic rotator cuff repair.

Hypothesis:

The primary hypothesis was that patients with glenohumeral chondral lesions will have inferior outcomes after arthroscopic rotator cuff repair compared with patients without chondral lesions. The secondary hypothesis was that patients with concomitant chondral lesions will have more severe preoperative symptoms compared with those without chondral lesions.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective analysis was performed of patients who underwent arthroscopic rotator cuff repair between 2008 and 2012. We examined the effects of chondral lesions on patient-determined outcomes, which included the Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), Single Assessment Numeric Evaluation (SANE), and the Shoulder Activity Level (SAL). Shoulders without chondral lesions were compared with shoulders with chondral lesions to determine whether differences in severity of preoperative symptoms as well as postoperative improvements were statistically significant.

Results:

A total of 281 shoulders were included from 273 patients, with a mean follow-up of 3.7 years. In total, 90 shoulders (32%) had concomitant chondral lesions in the glenohumeral joint. The presence and degree of chondral damage were not associated with the severity of preoperative symptoms or the amount of improvement after arthroscopic rotator cuff repair, as determined by patient outcome scores. Shoulders with bipolar chondral lesions had less postoperative improvement in their outcome scores compared with shoulders with unipolar lesions, with significant differences found in the SST (P = .0005), the SANE (P = .005), and the SAL (P = .04). Regardless of this, the majority of shoulders with bipolar chondral lesions (80%-92%) had postoperative improvements that superseded the minimal clinically important difference of the ASES, WORC, and SANE.

Conclusion:

At a mean 3.7-year follow-up, the presence of chondral damage did not appear to negatively affect the improvement in patient-determined outcomes after arthroscopic rotator cuff repair. However, improvement in outcomes was negatively affected by the presence of bipolar chondral lesions.

Glenohumeral Microfracturing of Contained Glenohumeral Defects: Mid- to Long-term Outcome

Purpose

To report mid- to long-term clinical and radiological outcomes after microfracturing for symptomatic chondral defects of the glenohumeral joint.

Methods

All patients who underwent glenohumeral arthroscopic microfracturing between 2002 and 2012 at a single center were considered for inclusion in this retrospective study. Clinical outcome was evaluated using the Constant Score, Oxford Shoulder Score, and Subjective Shoulder Value. Progression of joint space narrowing, sclerosis, marginal osteophytes, and presence of cysts over time were assessed using 4 different radiological grading systems.

Results

A total of 16 patients (n = 9 female, n = 7 male) with a mean age of 51.8 ± 12.6 years at the time of surgery and a mean follow-up of 122 ± 51.2 months (range, 61-204 months) were included in this retrospective study. Nine patients (56.3%) showed an isolated chondral defect, while 7 patients (43.8%) had concomitant pathologies. Constant Score (60.3 ± 12.7 vs. 85.9 ± 9.3; P < .001), Oxford Shoulder Score (29.0 ± 5.8 vs. 42.4 ± 4.5; P < .001), and Subjective Shoulder Value (23.9 ± 7.4 vs. 84.3 ± 10.9; P < .001) changed significantly from pre- to postoperative. The majority of patients (88%) were able to return to their preoperative level of activity. Three patients (19.8%) developed radiological signs of progressive glenohumeral degeneration during the study period. However, only 1 patient (6.25%) showed a progression of arthritic changes of more than 1 grade according to radiographic classifications. Two patients (12.5%) underwent revision surgery to a hemi shoulder arthroplasty during the study period at 12 and 36 months after the initial procedure.

Conclusions

Glenohumeral microfracturing is commonly performed together with other procedures, but seems to be a feasible treatment option for contained cartilage lesions in active patients reproducibly yielding good mid- to long-term outcome.

Level of Evidence

Level IV, therapeutic case series.

Autologous chondrocyte implantation for treatment of focal articular cartilage defects of the humeral head

BACKGROUND

Autologous chondrocyte implantation (ACI) constitutes an established treatment option for cartilage defects of the knee joint. Experience in the shoulder, however, is limited, and the management of cartilage defects remains a challenge. The purpose of this study was to evaluate the results after ACI with 3-dimensional spheroids of human autologous matrix-associated chondrocytes in the shoulder.

METHODS

Seven male patients (median age, 42.8 years [range, 18-55 years]) underwent ACI for symptomatic focal grade IV cartilage lesions of the humeral head by an open or arthroscopic approach. Clinical parameters (range of motion, visual analog scale score, Subjective Shoulder Value, Constant score, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score) and osteoarthritis grades were assessed. Arthroscopic re-evaluation was additionally performed in 5 patients.

RESULTS

After a median follow-up period of 32 months (range, 22-58 months), the median Subjective Shoulder Value was 95% (range, 70%-100%) compared with 60% (range, 30%-60%) preoperatively, the visual analog scale score was 0 at rest and was a median of 0 (range, 0-2) during exercise, the median Constant score was 95 points (range, 80-100 points), and the median American Shoulder and Elbow Surgeons score was 97 points (range, 90-100 points). The median preoperative size of the cartilage lesion was 3 cm² (range, 2.3-4.5 cm²). Arthroscopically, complete coverage of the cartilage defect was observed in 4 cases whereas a circumferential residual defect of 0.25 cm² was found in 1 patient. Grade I osteoarthritis (Samilson and Prieto classification) was observed in 2 cases. One patient had postoperative adhesive capsulitis and required revision surgery.

CONCLUSION

ACI using 3-dimensional spheroids of human autologous matrix-associated chondrocytes for treatment of grade IV articular cartilage lesions of the humeral head achieves satisfactory clinical results during a short- to mid-term follow-up period and leads to successful defect coverage with only minor radiologic degenerative changes. In this case series, ACI proved to constitute a viable treatment in the shoulder joint. However, in consideration of the 2-stage surgical design and the cost intensiveness of this procedure, the indication is restricted to young and active symptomatic patients in our practice.

Optimal management of glenohumeral osteoarthritis

Glenohumeral osteoarthritis (OA) is defined as progressive loss of articular cartilage, resulting in bony erosion, pain, and decreased function. This article provides a gross overview of this disease, along with peer-reviewed research by experts in the field. The pathology, diagnosis, and classification of this condition have been well described. Treatment begins with non-operative measures, including oral and topical anti-inflammatory agents, physical therapy, and intra- articular injections of either a corticosteroid or a viscosupplementation agent. Operative treatment is based on the age and function of the affected patient, and treatment of young individuals with glenohumeral OA remains controversial. Various methods of surgical treatment, ranging from arthroscopy to resurfacing, are being evaluated. The roles of hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty are similarly reviewed with supporting data.