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S E M I N A R S I N A R T H R O P L A S T Y 2 4 ( 2 0 1 3 ) 2 – 6

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Arthroscopic alternatives to total shoulder arthroplasty:You have got to be kidding

Samuel Dubrow, MDa, Yousef Shishani, MDb, and Reuben Gobezie, MDc,n

aCleveland Akron Shoulder and Elbow (CASE) Fellowship, The Cleveland Shoulder Institute, Department of Orthopaedic Surgery, UniversityHospitals of Cleveland, Cleveland, OHbThe Cleveland Shoulder Institute, University Hospitals of Cleveland, Cleveland, OHcDivision of Shoulder and Elbow Surgery, The Cleveland Shoulder Institute, Department of Orthopaedic Surgery, University Hospitals ofCleveland, Cleveland, OH

A R T I C L E I N F O

Keywords:

glenohumeral arthritis

arthroscopy

young patient

biologic resurfacing

527/$ - see front matter & 2013 Elseviedx.doi.org/10.1053/j.sart.2013.04.003

uel Dubrow, MD and Yousef Shishani,x, Naples, FL and Tornier, Edina, MN.ress reprint requests to Reuben Gobrook Dr, Monarch Center, Mayfield Hail address: clevelandshoulder@gma

A B S T R A C T

Shoulder arthroplasty is not an ideal surgical solution for young patients with arthritis of

the glenohumeral joint due to the concerns of long-term implant survival. Various open

and arthroscopic procedures have been described for this patient population with varying

results. Here we review current arthroscopic alternatives to total shoulder arthroplasty for

the treatment of glenohumeral arthritis. We also describe and present our outcomes of an

all-arthroscopic technique, using fresh osteochondral allograft to correct bipolar gleno-

humeral arthritis in young patients.

& 2013 Elsevier Inc. All rights reserved.

1. Introduction

Glenohumeral arthritis in young patients is a difficult prob-lem to treat. A number of treatment options exist, includingboth open and arthroscopic procedures. Open surgical proce-dures include traditional total shoulder arthroplasty, hemi-arthroplasty, arthrodesis, humeral head resurfacing, biologicglenoid resurfacing with or without humeral head replace-ment, autologous chondrocyte implantation, and osteochon-dral allograft resurfacing. Arthroscopic procedures includeglenohumeral debridement, capsular release, chondroplasty,microfracture, humeral head osteoplasty, axillary nervedecompression, biologic and non-biologic glenoid resurfac-ing, and osteochondral allograft resurfacing. When multipletreatment options exist to treat the same problem, it isusually the case that none is considered a “universal ideal”

r Inc. All rights reserved.

MD has nothing to disclo

bezie, MD, Department oeights, OH 44124.il.com (R. Gobezie).

procedure. As such, no agreement exists regarding theoptimal treatment for advanced glenohumeral arthrosis inthe young patient [1].Concern regarding the treatment of advanced glenohum-

eral osteoarthritis with bipolar chondral defects in youngpatients exists due to the expected failure of traditionalshoulder arthroplasty within the patient's lifetime, and thesubsequent need for revision surgery [2,3]. Shoulder arthro-plasty can also have substantial risks and may require post-operative restrictions on patients which may impair lifestyleor job requirements in younger individuals, in order tominimize the risk of prosthetic loosening [4].The purpose of this study was to review the arthroscopic

alternatives for the treatment of glenohumeral joint arthrosisin the young patient, as well as to describe our technique ofarthroscopic resurfacing using fresh osteochondral allograft.

se. Reuben Gobezie, MD is a consultant and receives support from

f Orthopaedic Surgery, University Hospitals of Cleveland, 5885

S E M I N A R S I N A R T H R O P L A S T Y 2 4 ( 2 0 1 3 ) 2 – 6 3

2. Arthroscopic treatment options

2.1. Debridement and capsular release

Arthroscopy has greatly enhanced our ability to diagnose andtreat various pathologies of the shoulder joint. Previousstudies have shown arthroscopic debridement to be effectivein treating osteoarthritis in select patient populations [4–6].Arthroscopic debridement and capsular release can smoothcartilage lesions, eliminate or reduce mechanical symptoms,and release capsular contractures, thereby producing satisfac-tory outcomes when used to treat patients with early osteo-arthritis of the shoulder [7]. Richards and Burkhart [8] believethat capsular release provides a reduction in joint contactpressures and a greater range of motion, thereby acting as theprimary mechanism of pain relief in young, active patientswith osteoarthritis. However, it has been shown that patientswho undergo arthroscopic debridement and capsular releasewith osteochondral lesions greater than 2 cm2 have had pooroutcomes [6]. Such arthroscopic procedures may provideimproved symptoms and function, delaying the need for amore extensive operation, such as arthroplasty, but it may notprevent the further deterioration of the arthritic joint [8].Millett and Gaskill [9] describe an arthroscopic technique

that combines debridement and capsular release with infe-rior humeral osteoplasty and axillary nerve decompression.They refer to this technique as comprehensive arthroscopicmanagement (CAM) of glenohumeral osteoarthritis [9,10]. Theindications for this procedure include young patients (ageo60 years) with glenohumeral osteoarthritis, and capsularcontractures and inferior humeral spurs that have failed non-operative methods [10]. The authors believe that inferiorhumeral osteophytes may compress the axillary nerve caus-ing pain, weakness, and decreased range of motion, whichosteoplasty (resection) of the inferior spur may relieve.

2.2. Microfracture

Microfracture was first described by Steadman et al. [11] as acartilage reparative strategy for the knee, by stimulatingfibrocartilage growth within a contained chondral defect.This technique has also been applied to the glenohumeraljoint. However, there are significant differences in articularcartilage between the shoulder and knee, which can impactresults when applied to the glenohumeral joint [12].The procedure involves first identification of the boundaries

of the cartilaginous defect, followed by debridement with anarthroscopic shaver or curette to obtain a stable periphery withvertically oriented chondral walls. A curette is then used toremove the calcified cartilage layer of the defect. An awl isthen used to penetrate the subchondral bone several times,approximately 2–3 mm apart, to produce bleeding bone [12].Osteochondral lesions of the shoulder treated with micro-

fracture have led to improvements in pain, activities of dailyliving, and the ability to participate in athletic activities [13].Snow and Funk [14] showed that upon reoperation of patientsthat had undergone arthroscopic microfracture, there wasgood filling of the chondral defect with fibrocartilage. Theauthors conclude in their study that microfracture of the

shoulder may be a useful technique to prevent furtherdeterioration of grade IV chondral lesions; however long-term follow-up is necessary [14]. Millett et al. [13] showed thegreatest improvements in those patients with microfractureof small unipolar humeral lesions, and the worst results inthose with bipolar lesions.

2.3. Biologic glenoid resurfacing

Several studies, with varying results, have looked at the resultsof biologic glenoid resurfacing with and without humeral headreplacement for the treatment of arthritis of the glenohumeraljoint in young patients [15–19]. These studies have looked atthe use of Achilles tendon, anterior capsule, fascia lata,meniscus, and human acellular dermal tissue matrix to resur-face the glenoid through open surgical techniques.Arthroscopic techniques of glenoid resurfacing have also

been reported using the Restore Patch (Depuy, Warsaw, IN),an implant of porcine origin, and Graftjacket (Wright Medical,Arlington, TN), a regenerative tissue matrix made fromhuman skin [20,21]. Pennington and Bartz [22] have alsodescribed an arthroscopic technique of glenoid resurfacingusing meniscus allograft. Savoie et al. [20] showed thatarthroscopic glenoid resurfacing provided statistically signifi-cant improvements in young patients with arthritis of theglenohumeral joint with a 3- to 6-year follow-up. Althoughfew studies exist looking at the results of arthroscopic bio-logic glenoid resurfacing [20,21], they tend to have a moreconsistent and favorable result when compared to the resultsof open surgeries [17–19].

2.4. Biologic total shoulder resurfacing using freshosteochondral allograft

Gobezie et al. [2] were the first to describe an all-arthroscopicbipolar biologic shoulder resurfacing technique. The proce-dure involves the use of fresh osteochondral allografts, whichare inserted entirely through the rotator interval underarthroscopic visualization, to replace the surfaces of theglenoid and humeral head; a cartilage transplant of theshoulder. Indications include a young patient (o50 years ofage) with arthritis in the absence of a large inferior humeralosteophyte, an intact rotator cuff with at least 901 of forwardelevation, and a centered glenohumeral joint (Fig. 1).The grafts are prepared first. Fresh osteoarticular allografts

are taken from a cadaveric humeral head and medial tibialcondyle or tibial plafond. The concavity of the medial tibialcondyle and distal tibial plafond are similar to that of theglenoid. The Osteochondral Autograft Transfer System(OATS) platform (Arthrex, Naples, FL) is used to prepare thegrafts. A 20-mm circular coring reamer is used on the tibialallograft for preparation of the glenoid resurfacing, which iscentered over a portion of the articular surface. The core isthen removed from the tibial allograft and cut to the desiredthickness of 5 mm by use of a 5-mm deep cutting guide. Thiscreates a graft of 20 mm in diameter and 5 mm in depth tobe used on the glenoid. The same procedure is then carriedout on the humeral allograft; however a larger graft can beprepared if desired, with a maximum diameter of 40 mm(Fig. 2).

Figure 1 – (A) AP and (B) axillary x-rays of the right shoulderof a 48-year-old male candidate for arthroscopic totalshoulder resurfacing with osteochondral allograft.

Figure 3 – Targeting guide used to prepare the transhumeralportal. The circular guide is placed on the humeral headregion to be resurfaced, which enters the joint through therotator interval. The drill sleeve is then placed on the lateralhumeral cortex and a wire is drilled directed towards thecircular guide. A cannulated reamer is then used over thewire to prepare the transhumeral tunnel. (Color version offigure is available online.)

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Arthroscopy is subsequently carried out with the patient inbeach chair position. Standard posterior and anterior portalsare made and a thorough inspection of the glenohumeraljoint is undertaken. The biceps tendon is then released fromthe superior labrum in order to provide room for the passageof instrumentation and the grafts into the joint. A subpectoralbiceps tenodesis is performed prior to the conclusion of thecase. The entire rotator interval is then resected using anarthroscopic shaver and cautery device through the anteriorportal, which is extended to 25–30 mm in length. This part iscrucial in order to have enough room for passing instrumen-tation and graft into the joint through the anterior portal.Arthroscopic reaming of the humeral and glenoid surfaces,

in preparation for the allografts, is conducted through the useof a transhumeral portal. In order to prepare this portal, atargeting guide is inserted through the anterior portal andcentered over the humeral head. The targeting guide isemployed much as an ACL guide is used to drill the tibialtunnel in arthroscopic anterior cruciate ligament reconstruc-tion (Fig. 3). However, for the transhumeral portal, the drillentry point is on the lateral humeral cortex and is directedtowards the center of the humeral head, where the targetingguide is placed. Next a circular 20-mm reamer is placedthrough the anterior portal and attached intra-articularly toa pin that enters the joint through the transhumeral portal.Once the reamer is connected to the pin, the humeral head isthen reamed in retrograde fashion to a depth of 5 mmthrough the transhumeral portal. The glenoid is then reamed,again through the transhumeral portal, however this timein antegrade fashion. It is possible to ream the humeral

Figure 2 – Fresh cadaveric osteochondral allografts areprepared using the Osteochondral Autograft Transfer System(OATS) platform (Arthrex, Naples, FL). (A) A prepared 20 � 5-mm tibial allograft used to resurface the glenoid. (B) A prepared30 � 5-mm humeral head allograft to be used for humeralresurfacing. (Color version of figure is available online.)

head to a larger size (maximum of 40 mm) if indicated for alarger graft.The prepared glenoid graft is then inserted into the joint

through the anterior portal. It is then positioned over thereamed glenoid surface and impacted into place. Chondraldarts of 1.2 mm are then used to fix the graft in place, whichare inserted through the transhumeral portal. Prior to inser-tion of the humeral graft a small drill hole is made throughits center to allow for the passage of a strong suture. A largeknot is tied on the articular side of the graft. This will thenact as a traction suture for the seating of the graft onto thehumeral head.A Nitinol wire is then fed through the transhumeral portal

into the glenohumeral joint and is retrieved through theanterior portal. The free end of the suture, which wasthreaded through the humeral graft, is then placed throughthe loop of the Nitinol wire, which is then pulled back out ofthe transhumeral portal bringing the suture with it. Thehumeral graft is then inserted through the anterior portaland traction is applied to the attached suture through thetranshumeral portal, seating the graft. The suture is thenremoved by grasping the knot on the articular surface of thehumeral graft, through the anterior portal, and retrieving itfrom the joint. Additional pressure is applied to the humeralallograft by moving the shoulder through a range of motionto compress it against the glenoid (Fig. 4).

3. Discussion

The procedure provides a biologic resurfacing of an arthriticglenohumeral joint, while preserving bone stock, therebyallowing for the possibility of later conversion to a standard

Figure 4 – (A) Passage of the Nitinol wire through the transhumeral portal, exiting through the area of reamed surface inpreparation for insertion of the humeral allograft. The glenoid graft was previously inserted and is visualized on the left sideof the arthroscopic picture. (B) The humeral head allograft is being pulled into position via a “pull suture” that was broughtthrough the transhumeral tunnel via the Nitinol wire. (C) Humeral allograft in position on the reamed surface with digitalpressure applied to it. The knot from the “pull suture” will then be retrieved through the anterior portal. (D) Arthroscopic viewof the articular surface after completion of the procedure. (Color version of figure is available online.)

S E M I N A R S I N A R T H R O P L A S T Y 2 4 ( 2 0 1 3 ) 2 – 6 5

total shoulder replacement if needed (Fig. 5). It also limits thedamage to the surrounding structures including the subsca-pularis, as it is performed arthroscopically through therotator interval. This greatly decreases the morbidity andrehabilitation required after surgery when compared to astandard total shoulder replacement [2].The treatment of glenohumeral arthritis in the young

patient remains a challenging issue. A recognized need existsfor an alternative to the current treatment strategies in thispatient population. A variety of arthroscopic options exist forthe treatment of glenohumeral arthritis in the young patient,however no consensus exists as to which option provides themost reliable long-term outcomes.It appears that this arthroscopic technique of biologic total

shoulder resurfacing using fresh osteochondral allograftcan be an alternative and appropriate treatment strategy forglenohumeral arthritis in the young patient. Althoughlong-term results of this procedure do not exist, we haveobtained promising results in 1–2 year follow-up. The seniorauthor (R.G.) has performed this procedure on 22 patients.There has been one failure of a humeral head graft,which was revised to a prosthetic humeral head resurfacingarthroplasty. Mean visual analog pain scores have improved

Figure 5 – Postoperative (A) AP and (B) axillary x-rays of thepatient shown in Figure 1, showing increased glenohumeraljoint space and a smooth articular surface.

from 6 to 1. The mean American Shoulder and ElbowSurgeons score has improved from 40 to 83. Range of motionin forward elevation has improved from 1281 to 1371. Ourearly results have been encouraging, but long-term follow-upis needed.

r e f e r e n c e s

[1] Kipp MA, Nguyen D, Bigliani LU. Surface replacement optionsin the young patient with advanced glenohumeral arthritis.Semin Arthroplasty. 2008;19:54–7.

[2] Gobezie R, Lenarz CJ, Wanner JP, Streit JJ. All-arthroscopicbiologic total shoulder resurfacing. Arthroscopy. 2011;27(11):1588–93.

[3] Cole BJ, Yanke A, Provencher MT. Nonarthroplasty alterna-tives for the treatment of glenohumeral arthritis. J ShoulderElbow Surg. 2007;16:231S–40S.

[4] Van Thiel GS, Sheehan S, Frank RM. Retrospective analysis ofarthroscopic management of glenohumeral degenerativedisease. Arthroscopy. 2010;26(11):1451–5.

[5] Weinstein DM, Bucchieri JS, Pollack RG, Flatow EL, BiglianiLU. Arthroscopic debridement of the shoulder for osteoar-thritis. Arthroscopy. 2000;16:471–6.

[6] Cameron BD, Galatz LM, Ramsay ML, Williams GR, IannottiJP. Non-prosthetic management of grade IV osteochondrallesions of the glenohumeral joint. J Shoulder Elbow Surg.2002;11:25–32.

[7] Van der Majien OA, Gaskill TR, Millett PJ. Glenohumeral jointpreservation: a review of management options for young,active patients with osteoarthritis. Adv Orthop. 2012;2012:doi: 10.1155/2012/160923.

[8] Richards DP, Burkhart SS. Arthroscopic debridement andcapsular release for glenohumeral osteoarthritis. Arthro-scopy. 2007;23(9):1019–22.

[9] Millett PJ, Gaskill TR. Arthroscopic management of gleno-humeral arthrosis: humeral osteoplasty, capsular release,and arthroscopic axillary nerve release as a joint-preservingapproach. Arthroscopy. 2011;27(9):1296–303.

[10] Millett PJ, Horan MP, Pennock AT, Rios D. Comprehensivearthroscopic management (CAM) procedure: clinical resultsof a joint-preserving arthroscopic treatments for young,

S E M I N A R S I N A R T H R O P L A S T Y 2 4 ( 2 0 1 3 ) 2 – 66

active patients with advanced shoulder osteoarthritis.Arthroscopy. 2013;29(3):440–8.

[11] Steadman JR, Rodkey WG, Rodrigo JJ. Microfracture: surgicaltechnique and rehabilitation to treat chondral defects. ClinOrthop Relat Res. 2011;S391:362–9.

[12] Bhatia S, Hsu A, Lin E et al. Surgical treatment options forqthe young and active middle-aged patient with glenohum-eral arthritis. Advances in Orthopedics. 2012:2012; doi:10.1155/2012/846843.

[13] Millett PJ, Huffard BH, Horan MP, Hawkins RJ, Steadman JR.Outcomes of full-thickness articular cartilage injuries of theshoulder treated with microfracture. Arthroscopy. 2000;16(5):471–6.

[14] Snow M, Funk L. Microfracture of chondral lesions of theglenohumeral joint. Int J Shoulder Surg. 2008;2:72–8.

[15] Burkhead WZ, Hutton KS. Biologic resurfacing of the glenoidwith hemiarthroplasty of the shoulder. J Shoulder ElbowSurg. 1995;4(4):263–70.

[16] Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ. Hum-eral hemiarthroplasty with biologic resurfacing of the glenoidfor glenohumeral arthritis: two to fifteen year outcomes.J Bone Joint Surg Am. 2007;89(4):727–34.

[17] Nicholson GP, Goldstein JL, Romeo AA, Cole BJ, Hayden JK,Twigg SL, et al. Lateral meniscus allograft biologic glenoidarthroplasty in total shoulder arthroplasty for young patientswith degenerative joint disease. J Shoulder Elbow Surg.2007;16(S5):S261–6.

[18] Elhassan B, Ozbaydar M, Diller D, Higgins LD, Warner JP. Softtissue resurfacing of the glenoid in the treatment of gleno-humeral arthritis in active patients less than fifty years old.J Bone Joint Surg Am. 2009;91(2):419–24.

[19] Verma NN, Strauss E, Salata M, McGill KC, Nicholson G, ColeBJ, et al. Failure rate of biologic resurfacing of the glenoid inyoung patients with glenohumeral arthritis. Arthroscopy.2011;24(s5):e42.

[20] Savoie FH, Brislin KJ, Argo D. Arthroscopic glenoid resurfacingas a surgical treatment for glenohumeral arthritis in the youngpatient: midterm results. Arthroscopy. 2009;25(8):864–71.

[21] Bhatia DN, van Rooyen KS, du Toit DF, de Beer JF. Arthro-scopic technique of interposition arthroplasty of the gleno-humeral joint. Arthroscopy. 2006;22(5):570e1–5.

[22] PenningtonWT, Bartz BA. Arthroscopic glenoid resurfacing withmeniscal allograft: a minimally invasive alternative for treatingglenohumeral arthritis. Arthroscopy. 2005;21(12):1517–20.