Debridement, Chondroplasty, and Soft Tissue Releases

CHAPTER PREVIEW

CHAPTER SYNOPSIS

Arthroscopic debridement of the osteoarthritic shoulder is an effective treatment option in the young, active patient or in the medically fragile patient. Concomitant shoulder pathology, such as rotator cuff disease, impingement syndrome, and acromioclavicular arthritis should be addressed at the time of surgery. Early reported results have been encouraging with regard to pain relief and restoration of function in short-term follow-up, even in patients with severe glenohumeral arthritis. The role of capsular release, glenoidplasty, and microfracture has not been clarified based on current data. Although it is not a substitute for joint replacement arthroplasty, arthroscopic debridement provides a treatment alternative for some patients and may delay the need for prosthetic replacement.

IMPORTANT POINTS:

1

Severe arthritis is not a contraindication to arthroscopic debridement.
2

Arthroscopic debridement should be accompanied by subacromial bursectomy.
3

It is important to manage patient expections; this is a temporizing procedure.
4

Ideal candidates are young, active patients and older, debilitated patients with glenohumeral arthritis.

CLINICAL/SURGICAL PEARLS:

1

It may be hard to enter the joint due to contracture and stiffness; thus, placing the trochar above the humeral head may be the easier way to gain access to the joint.
2

In addition to irrigation and removal of loose fragments and torn tissue, subacromial bursectomy is imperative to success.
3

Care should be taken to remove the subacromial bursa without removing the coracoacromial ligament, as this ligament may be important later to prevent humeral head escape if the patient needs arthroplasty.
4

There does not appear to be a need to remove inferior osteophytes.
5

Early range of motion is to be encouraged.

CLINICAL/SURGICAL PITFALLS:

1

There may be difficulty entering the joint; fluoroscopy can be considered but rarely, if ever, is necessary.
2

If capsulotomy is considered, not cutting the capsule inferiorly (6 o’clock) is preferred, due to the close proximity of the axillary nerve. Instead, performing the capsulotomy to 5 o’clock and again at 7 o’clock, then performing a manipulation, may reduce the risk of iatrogenic axillary nerve injury.

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The management of a painful, arthritic shoulder in a young, active patient, or in a patient who is too ill or frail to undergo an arthroplasty, poses a treatment dilemma for the orthopedic surgeon. Nonoperative treatment may not provide satisfactory pain relief, and patients may become frustrated by their functional decline or by pain, which may be constant or awaken them at night. The primary goals in management are pain relief and restoration of function. Total shoulder arthroplasty offers the most favorable results in this regard. However, the long-term success of shoulder arthroplasty in the younger patient is more difficult to achieve due to the increased stresses placed on the prosthesis from greater physical demands. The risk of loosening, wear, or other need for revision and the less satisfactory results of revision arthroplasty (as compared with a primary replacement) instill caution in the orthopedic surgeon. The other group that conceptually would benefit from arthroscopic methods of management of shoulder arthritis includes the older or medically fragile patient, in whom more prolonged anesthesia or larger fluid shifts may be detrimental.

Sperling and Rowland reported on 78 patients 50 years or younger with arthritic shoulders treated with either hemiarthroplasty or total shoulder arthroplasty, with a minimum 15-year follow-up. The estimated survival rate, defined as being free of revision, for hemiarthroplasty was 75% and for total shoulder arthroplasty was 84% at 20 years. Marked long-term pain relief and improvement in motion were found with shoulder arthroplasty. However, with the Neer clinical rating system, nearly half these patients were found to have an unsatisfactory result, due mostly to limitations in motion. The authors concluded that great care must be exercised, and alternative methods of treatment considered, before shoulder joint replacement arthroplasty is offered to patients age 50 years or younger. Reasons for revision surgery after total shoulder arthroplasty include infection, glenoid loosening, and rotator cuff tearing. A leading reason for revision surgery after hemiarthroplasty is painful glenoid erosion.

Therefore, nonarthroplasty treatment options should be actively considered in young, active patients prior to prosthetic replacement. This includes arthroscopic debridement, removal of loose bodies, and chondroplasty, with or without soft tissue releases. The results of arthroscopic debridement of knee osteoarthritis have been reported and may be influenced by a placebo effect. Although a similar prospective randomized study has not yet been reported for the shoulder, clinical studies have indicated that arthroscopic treatment is successful in some patients. The literature is sparse in this area, though the data suggest that the results of arthroscopy for arthritis may be related to the severity of the arthritis and whether the osteochondral lesions exist on both the humeral head and glenoid articular surface.

In addition to young arthritic patients, older or medically fragile patients would benefit from arthroscopic methods of management of shoulder arthritis as well. The systemic stress of a larger operation, such as arthroplasty of the shoulder, can be significant due to large fluid shifts and damage and healing of the open, extensile approach to the shoulder, as compared with shoulder arthroscopy. Shoulder arthroscopy requires small incisions and is a shorter operation, with less fluid shifts, less blood loss, and less soft tissue dissection and subsequent healing. Thus, while data are lacking to prove this point, it would nonetheless seem logical that the older, medically fragile patient may also benefit from an arthroscopic approach to glenohumeral arthritis.

The Outerbridge classification, although originally used to describe chondral and osteochondral lesions of the patella, has been used clinically to describe chondral and osteochondral lesions in other joints, including the shoulder. Outerbridge grade I lesions are characterized by softening of the articular surface; grade II is characterized by fissuring of the hyaline articular cartilage; grade III is characterized by a “crabmeat” fibrillar appearance of the cartilage; and grade IV is that with exposed subchondral bone.

CLINICAL EXAMINATION

Often arthritis and chondral and osteochondral lesions do not occur in isolation. Coexistent shoulder pathology includes: rotator cuff impingement, as well as partial- and full-thickness tearing; acromioclavicular joint arthritis; biceps tendinopathy; and capsular contractures. The surgeon should be aware of concomitant pathology preoperatively, and a thorough shoulder examination should include testing for other sources of shoulder pain. Because the shoulder pain secondary to advanced osteoarthritis may present as global and severe, with pain at the end points of motion, it may be difficult to differentiate other sources of pathology preoperatively. Therefore, a careful and focused shoulder examination should be performed whenever possible. These other causes of shoulder pain may be addressed at the time of surgery despite the presence of osteoarthritis.

Active and passive range of motion of the shoulder should be recorded, and the presence of crepitus is noted. Neer and Hawkin’s impingement signs should be tested. Tenderness to palpation at the acromioclavicular joint and pain with cross-arm adduction should be recorded. Tenderness to palpation of the proximal biceps tendon within the bicipital groove and Speed’s and Yergason’s tests should be recorded. Atrophy and scapulothoracic motion should be assessed. Additionally, strength should be evaluated, ideally within the pain-free range of motion.

IMAGING STUDIES

Radiographic studies should include a “true” anteroposterior (AP) view, or Grashey view, of the shoulder, performed perpendicular to the scapular plane, rather than to the plane of the body. The x-ray beam is angled approximately 40 degrees laterally in order to obtain proper view of the glenohumeral joint space. In addition, an axillary view of the shoulder is performed to evaluate for eccentric glenoid wear and the presence of glenohumeral subluxation ( Fig. 2-1 ). Radiographic changes of osteoarthritis include joint space narrowing, inferior humeral osteophyte formation, subchondral cyst formation, and subchondral sclerosis ( Fig. 2-2 ). Radiographically, loose bodies may also be seen. When there is clinical suspicion of rotator cuff, biceps tearing, or other soft tissue pathology, a magnetic resonance imaging (MRI) study is obtained to confirm the diagnosis.

INDICATIONS FOR SURGERY

Indications for surgery include patients who have failed at least 3 months of nonoperative treatment, with crepitus on range-of-motion examination of the shoulder. Nonoperative treatment includes a trial of physical therapy for maintenance of range of motion, oral nonsteroidal anti-inflammatory medications, and intra-articular injection of corticosteroids. Epis et al. recently documented successful pain relief at short-term follow-up of 6 months in patients with Milwaukee shoulder syndrome who had simple closed-needle irrigation of the shoulder followed by cortisone injection.

Although the senior author considers arthroscopic debridement in the algorithm of shoulder arthritis, regardless of age, most consider this a reasonable time-buying option for young, active patients and for elderly patients with medical co-morbidities that would preclude a major reconstructive procedure. Physiologically young patients (age less than 60) with the diagnosis of osteoarthritis, mild losses in range of motion, and concentric wear of the glenohumeral joint may be the best candidates for surgery. The age level is dependent on the individual, but such activities as heavy manual labor occupations and contact sports are not recommended in patients with a total shoulder arthroplasty. These patients may be best served with a more minor procedure such as arthroscopic debridement. Shoulder arthroscopy has been shown to be a safe procedure with a low complication rate.

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