CHAPTER 34 Biologic Glenoid Resurfacing

Biologic resurfacing of the glenoid has been performed with various materials, including fascia lata autograft, fascia lata allograft, meniscal allograft, and Achilles tendon allograft.¹ The main advantage of biologic glenoid resurfacing lies in providing a new articulating surface for the glenoid while avoiding potential late-term complications associated with polyethylene wear and failure. Consequently, consideration of biologic glenoid resurfacing is most reasonable in younger patients. Biologic glenoid resurfacing also allows resurfacing of localized glenoid articular cartilage lesions that may result from trauma in young patients. In our practice, we almost always combine biologic glenoid resurfacing with humeral head arthroplasty (hemiarthroplasty or surface replacement) because our patients with glenoid articular cartilage disease almost always have associated humeral head articular cartilage disease.

Of the available tissues for use in biologic glenoid resurfacing, we prefer autogenous fascia lata. Use of the patient’s own tissue minimizes the risk of graft rejection, a phenomenon that we have observed with allografts. Additionally, the morbidity associated with harvest of a fascia lata autograft is minimal.

INDICATIONS AND CONTRAINDICATIONS

Indications in our practice for biologic glenoid resurfacing are limited to a young patient (<40 years old) with glenoid disease; in an older patient, the use of a prosthetic glenoid component would be indicated. We have performed biologic resurfacing most commonly in patients with a generalized arthritic condition (i.e., glenohumeral chondrolysis; Fig. 34-1) but have also used it for localized traumatic glenoid articular cartilage lesions. One situation in which we opt for a prosthetic glenoid component in a young patient is a diagnosis of juvenile rheumatoid arthritis.

Figure 34-1 Radiograph of a young patient with glenohumeral joint chondrolysis after shoulder arthroscopy.

A rare situation in which we use biologic glenoid resurfacing is a revision case with a competent rotator cuff in which hemiarthroplasty has resulted in symptomatic glenoid erosion and insufficient bone exists to permit prosthetic resurfacing (Fig. 34-2). In these scenarios, biologic resurfacing represents an alternative to resection arthroplasty (see Chapter 35 for more on indications for revision shoulder arthroplasty). In most primary cases in older patients in whom unconstrained arthroplasty is indicated yet insufficient glenoid bone exists for prosthetic resurfacing, we generally perform isolated hemiarthroplasty because most of these patients obtain satisfactory pain relief and function (although these results are inferior to those obtained with total shoulder arthroplasty) without prosthetic or biologic glenoid resurfacing.

Figure 34-2 Glenoid erosion after hemiarthroplasty. The residual glenoid bone is insufficient to permit insertion of a prosthetic glenoid component.

Contraindications to biologic glenoid resurfacing include the standard contraindications to unconstrained shoulder arthroplasty. Additionally, any situation in which the native glenoid is insufficient to allow anchorage of the biologic tissue is a contraindication to biologic resurfacing (Fig. 34-3).

Figure 34-3 Glenoid insufficiency preventing anchorage of a biologic resurfacing graft.

TECHNIQUE FOR BIOLOGIC GLENOID RESURFACING

Autogenous Fascia Lata Harvest

The operating room setup, anesthesia, patient positioning, skin preparation, surgical draping, and surgical approach are identical to that for other shoulder arthroplasties. Additionally, the contralateral lower extremity and hip region are prepared and draped (Fig. 34-4). Using the contralateral lower extremity permits an assistant to close the fascia lata harvest wound while the approach is made to the shoulder. An 8-cm incision is started 3 cm distal to the greater trochanter of the femur and extended distally along the longitudinal axis of the femur (Fig. 34-5). A needle tip electrocautery is used to obtain hemostasis and aids in dissection through the subcutaneous layer down to the fascia lata. The fascia lata is cleared of the overlying subcutaneous fat to complete the exposure (Fig. 34-6). A scalpel is used to harvest an 8-cm-long by 3-cm-wide segment of fascia lata (Fig. 34-7). The wound is irrigated; it is not necessary to close the residual defect in the fascia lata (Fig. 34-8). The subcutaneous tissue is closed with 2-0 absorbable braided suture in an interrupted technique. The skin is closed with 3-0 absorbable monofilament suture in a continuous running subcuticular technique. Steri-Strips and sterile dressings are applied. The fascia lata is folded to double its thickness. Braided 2-0 absorbable suture is used to suture the perimeter of the autograft (Fig. 34-9).