The optimal treatment of young, active individuals with postreconstruction, posttraumatic, and/or primary shoulder osteoarthritis is unclear. Glenoid component loosening and osteolysis secondary to polyethylene wear are the main factors affecting the functional outcomes and, subsequently, long-term survivorship following total shoulder arthroplasty. The risk of glenoid-related complications in a young patient population is increased due to an increased activity level and longer life of the prosthesis. Hemiarthroplasty is an attractive treatment option for young patients with glenohumeral arthritis; however, a long-term follow-up has revealed a high percentage of patients with unsatisfactory results according to Neer’s criteria.⁴³ In the mid-1980s, porous-coated metalbacked glenoid components were developed to increase the longevity of shoulder replacements and potentially allow their application to this younger and more active population. Discouraging case reports and case series soon appeared, documenting a high incidence of failure of metal-backed glenoid components due to eccentric implant wear, polyethylene dissociation, instability, osteolysis, and third body wear.⁶,¹⁰,¹¹,¹⁷,¹⁸,³⁰,⁴⁴

Biologic resurfacing of the glenoid was developed to address these issues. The goal of this procedure was to create a permanent and durable bearing surface that would theoretically preserve motion, provide pain relief, and improve function, while avoiding the complications associated with implantation of a polyethylene glenoid component. This chapter reviews the historical basis of biologic resurfacing, our near 25-year experience with the procedure, and current developments in biologic glenoid resurfacing.

The concept of biologic materials for the resurfacing of articular surfaces is not a new one.²,³,⁸,⁹,¹²,¹³,¹⁶,¹⁹,²¹,²³,²⁴,²⁵,²⁶,³¹,³⁴,³⁶,³⁸,⁴⁰,⁴⁶ As early as 1860, Veneriel described a fascial arthroplasty of the temporomandibular joint.⁴⁷ In 1904, Murphy performed fascial arthroplasty of the knee and elbow as well as the shoulder,³³ using the fat that remained attached to the fascia to further decrease the coefficient of friction. MacAusland, in a 1921 review, detailed all of the materials that had been used to realign human joints.²⁹ Attempts using non-absorbable materials included the use of ivory pegs, magnesium sheets, wood, celluloid, gutta percha, gauze packing, yellow wax and lanolin, cellophane, nylon, and rubber. Techniques using autograft were also numerous and included attempts using periosteum, fascial and muscle flaps, bursal flaps, fat, cartilage transfers, and skin. Xenograft with chromacized pig bladder had also been described.¹

There are numerous ways to biologically resurface arthritic joints. However, one of the underlying principles is to provide an immediate smooth surface with a low coefficient of friction. This surface also provides intermittent pressure to the underlying cancellous surface and blood clot that eventually results in metaplasia. This concept was first introduced by Smith-Petersen in 1939 with a two-stage, mold arthroplasty of the hip joint.⁴¹ He used an inert mold (vitallium) interposed between two cancellous bone surfaces.
He theorized that invasion of the subsequent blood clot by fibroblasts in combination with gentle friction and intermittent pressure would lead to a metaplasia of the invading cells and the formation of fibrocartilage. He further hypothesized that, eventually, the articular hyaline cartilage would form. In fact, in his 1948 article, he did demonstrate what appeared to be true hyaline cartilage.⁴²

Uncemented or cemented humeral hemiarthroplasty with biologic resurfacing of the glenoid using autograft or allograft is a reliable treatment option. Ipsilateral anterior glenohumeral capsule or autogenous fascia lata have been used extensively in early reports documenting nonprosthetic biologic resurfacing of the glenohumeral joint. Currently, allograft tissue is used for both interpositional arthroplasty and biologic resurfacing due to unpredictable outcomes and concerns regarding the durability of anterior capsule and autogenous fascia lata.

Classically, the allograft of choice has been the Achilles tendon. Tendo-Achilles allograft is durable, low cost, and readily available. The collagen makeup of the Achilles tendon is thought to provide beneficial wear characteristics as the new glenoid surface. Recent work has demonstrated the significant intermediate and long-term results of tendo-Achilles allograft in resisting glenoid erosion and maintaining glenohumeral joint space.²⁷

In contrast to the above results, Elhassan et al. published the results of 13 patients (average age of 34 years), with glenohumeral arthritis managed with biologic glenoid grafting and humeral hemiarthroplasty. The Achilles tendon was used in 11 patients, one patient received autogenous fascia lata, and in one patient anterior shoulder capsule was used to resurface the glenoid. Ten patients had a humeral hemiarthroplasty performed; the remaining three patients underwent humeral resurfacing. Revision was performed in 10 patients for persistent pain and poor range of motion at an average of 14 months postoperatively. Two patients experienced postoperative infections. One patient had good function, pain relief, and improved range of motion. The authors concluded that the Achilles tendon allograft glenoid resurfacing was not a reliable treatment option for the management of glenohumeral arthritis in young patients.²⁰

Technical considerations and concerns for tissue reaction, overstuffing, and/or lateralizing the joint have led some to abandon the use of bulky materials in favor of more manageable materials, such as allograft meniscus. In addition to less bulk, the theoretical advantages of lateral meniscus allograft include an established history of synovial healing in the knee and a wedge shape, which compensates for preexisting posterior glenoid wear and provides inherent stability. Ball et al. were the first to describe glenoid resurfacing with meniscal allograft when they reported the results of 6 shoulders with an average 24-month follow-up.⁴ They showed promising patient satisfaction, pain relief, and significant improvements in range of motion. The radiographic results of these patients were also promising with no glenoid erosion and maintenance of the glenohumeral joint space. Furthermore, a recent biomechanical study suggests that lateral meniscus allografts are durable under physiologic and pathologic loads across the shoulder joint.¹⁴ Wirth et al. reported significant improvement in all 10 functions of the American Shoulder and Elbow Society questionnaire in 30 patients following lateral meniscal allograft biologic glenoid resurfacing with an average 3-year follow-up. The radiographic analysis showed a 51% decrease in glenohumeral joint space over 3 years; however, no progression of posterior glenoid erosion was noted.⁴⁹ Similar reports have demonstrated success in the short-term utilization of lateral meniscus allograft.³⁵,⁴⁵ Unfortunately, there are no peer-reviewed reports documenting long-term outcomes with regard to progressive glenoid erosion. Nicholson et al. retrospectively demonstrated that lateral meniscus allograft provided significant pain relief, range-of-motion gains, and patient satisfaction at 1-year follow-up. The radiographic analysis revealed the average joint space was 1.8 mm on anteroposterior projection and 1.6 mm on axillary view at 1 year. This did not constitute a significant loss of glenohumeral joint space. Despite showing these favorable results, the complication rate and reoperation rate was 17% within the first postoperative year.³⁵