Nonarthroplasty Options for Glenohumeral Arthritis and Chondrolysis

Chapter 36


Nonarthroplasty Options for Glenohumeral Arthritis and Chondrolysis







Important Points



• Patient age and desired activity level are important preoperative considerations.


• Global location of the defect (glenoid surface, humeral head, or bipolar “kissing” lesions), local location of the defect (central, peripheral), and size, depth, and containment of the defect must be thoroughly assessed for optimal management.


• A true anteroposterior (AP) and axillary views should be used to assess for subtle glenohumeral joint space changes.


• Bony version should be assessed. Nonarthroplasty options have limited success if extensive posterior or posteroinferior glenoid bone loss is present.


• Assess posterior humeral translation on the glenoid. If posterior subluxation is present, this may indicate worse outcomes with nonarthroplasty options.


• Advanced (bipolar) glenohumeral disease can be initially treated with nonarthroplasty options, including capsular release and synovectomy, with less predictable results for interpositional arthroplasty and biologic options.



Clinical and Surgical Pearls



• Isolated chondral lesions of the glenohumeral joint are rare, but can be debilitating. It is crucial to identify which lesions are incidental and which are truly symptomatic.


• Range-of-motion deficits may exist as a manifestation of cartilage damage, arthritis, and resultant capsular synovitis, thickening, and contracture.


• Nonarthroplasty techniques include palliative, reparative, restorative, and reconstructive surgical techniques.


• Arthroscopic debridement including synovectomy and tailored capsular release (capsulectomy) can help treat range-of-motion deficits.


• When performing microfracture long-handled curettes and awls are used to create clean lesion edges and adequate marrow stimulation.


• Autologous chondrocyte implantation has been described for isolated humeral head defects.


• Osteochondral autografts and allografts can be used to treat lesions with combined cartilage and bone loss.


• Interpositional arthroplasty uses a variety of allograft materials including lateral meniscus, Achilles tendon, and fascia lata.



Glenohumeral arthritis and chondrolysis in the young, active patient population represent difficult clinical scenarios for even the most experienced of orthopedic surgeons. Even the diagnosis of symptomatic cartilage lesions can be challenging, as these patients often have multiple injuries and varying pain complaints making it difficult to determine which pathology is the primary generator of symptoms. A thorough understanding of shoulder pathoanatomy is critical for appropriate clinical decision making to provide effective treatment. Overall, the diagnosis of a symptomatic chondral injury is one of exclusion.1 Whereas isolated articular cartilage lesions of the glenohumeral joint are rare, these lesions can become extremely painful and functionally limiting. Nonoperative treatment includes activity modification, physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and intra-articular injections of corticosteroids and/or hyaluronic acid solutions (off-label usage). Unfortunately, their effects are usually temporary at best. Surgical options range from simple arthroscopic treatment to arthroplasty. Total shoulder arthroplasty remains the gold standard for glenohumeral arthritis treatment and is successful at relieving pain and restoring function. Concerns regarding component loosening, ability to perform high-level athletic activity, and the potential need for early revision surgery make this a less attractive option in a younger patient population. Other surgical treatment options range from palliative arthroscopic debridement and capsular release (capsulectomy) to reparative (microfracture), restorative (osteochondral autograft or allograft and autologous chondrocyte implantation [ACI]), and reconstructive surgical techniques (biologic resurfacing). With recent advances in diagnostic modalities, surgical techniques, and biologic implants, the treatment algorithm for these difficult patients is evolving, and no single nonarthroplasty option has been identified as the gold standard. The purposes of this chapter are to provide an overview of the typical patient with glenohumeral arthritis or chondrolysis, to discuss patient evaluation and appropriate clinical decision making, and finally to describe the various nonarthroplasty surgical treatment options for these challenging clinical situations.



Preoperative Considerations



History


As previously described, articular cartilage lesions of the shoulder are often incidental findings discovered during preoperative imaging studies or during diagnostic arthroscopy. Treating asymptomatic lesions can be detrimental because the true cause of symptoms may be ignored or missed, and the treatment itself may cause further damage to the chondral surface. It is critical to determine if glenoid or humeral head articular cartilage lesions are truly symptomatic, and the diagnostic approach begins with a thorough patient history. In patients with multiple shoulder pathologies and those who have undergone prior operations, it is even more challenging to determine if current articular defects were actually responsible for their previous, preoperative symptoms. In addition, patients with previous shoulder surgery and intra-articular pain pump placement are at risk for the development of postsurgical glenohumeral chondrolysis.27 During the initial office visit, the clinician should inquire about the following:





Physical Examination


A complete physical examination of both shoulders should be performed for every patient being evaluated for symptomatic chondral defects. Range of motion (ROM), strength, sensation, and stability of the affected shoulder are compared with those of the contralateral shoulder. Loss of active or passive motion must be documented and corrected preoperatively. Early identification of stiffness allows time to restore deficits before operative treatment for chondral defects. Special shoulder tests should be performed when necessary to evaluate for comorbidities or rule out other causes for the patient’s symptoms. Common (though not specific) physical examination findings in this patient population may include the following:



• Tenderness to palpation—rule out subacromial bursitis


• Decreased ROM



– Decreased forward flexion caused by an inferior humeral head spur.


– Decreased external rotation caused by a flattened humeral head.


– Decreased external rotation at the side (ERs) can indicate anterior capsular contracture, including the rotator interval, the superior and middle glenohumeral ligament, and the coracohumeral ligament (Fig. 36-1).



– Decreased abduction and external rotation (ABER) can indicate anterior and anteroinferior capsule contracture.


– Decreased abduction and internal rotation (ABIR) can indicate posterior and posteroinferior capsule contracture (Fig. 36-2).



– Decreased abduction (ABD) can indicate inferior capsule contracture and possible involvement of the superior capsule or superior labral anterior-posterior (SLAP) region.


• Crepitus with ROM—painless versus painful


• Clicking, catching, or locking with ROM


• Normal strength and sensation



Imaging


Imaging studies are routinely used in the evaluation of glenohumeral chondral lesions and typically include radiographs, magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and computed tomography (CT). Despite advances in imaging techniques, glenohumeral articular surface defects may not be easily seen on plain radiographs or with other advanced imaging modalities, and glenohumeral arthroscopy remains the gold standard for diagnosis. Imaging is, however, extremely helpful not only for diagnosis, but especially for preoperative planning. Specific planning considerations include the chondral anatomy of the shoulder joint. Normally the humeral head cartilage is thickest in the center (1.2 to 1.3 mm thick) and thinner at the periphery (less than 1.0 mm thick).8 In contrast, the glenoid cartilage is thickest along the periphery, tapering centrally to the bare area where it is completely devoid of cartilage. Knowledge of normal anatomy in conjunction with information supplied by imaging studies helps determine the significance of lesions based on their location along the humeral head and/or glenoid surface.



Radiographs


Every patient should undergo a standard radiographic series of the shoulder including an anteroposterior (AP) view, a true AP view (especially important to assess subtle joint space changes), a scapular-Y view, and an axillary lateral view. These views evaluate the joint space for glenohumeral arthritis and may show overt bony abnormalities. Other specific radiographs include the Stryker notch view to evaluate Hill-Sachs lesions and the Garth (apical oblique) view to evaluate glenoid bone loss4 (Fig. 36-3). The earliest signs of glenohumeral wear are usually in the posteroinferior quadrant of the shoulder and may demonstrate joint space narrowing or subtle posterior joint subluxation (Fig. 36-4).







Indications and Contraindications




Relative Contraindications



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Sep 11, 2016 | Posted by in SPORT MEDICINE | Comments Off on Nonarthroplasty Options for Glenohumeral Arthritis and Chondrolysis

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