Surgical Treatment Options for the Young and Active Middle-Aged Patient with Glenohumeral Arthritis
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While the cause of primary glenohumeral osteoarthritis is largely unknown, secondary osteoarthritis is often due to trauma, acute or recurrent dislocation, or prior surgery. Primary glenohumeral arthritis typically results in posterior glenoid wear with posterior humeral head subluxation occurring in up to 50% of affected shoulders. Rotator cuff tears occur in less than 5–10% of cases of primary osteoarthritis. Joint space narrowing occurs with periarticular osteophyte formation most commonly on the inferior aspect of the humeral head. As a result, the anterior soft tissues such as the capsule and subscapularis become contracted and stiff, limiting external rotation. With the growing elderly population in the US, the number of total shoulder arthroplasties performed each year has doubled over the past decade to approximately 20,000 cases. While glenohumeral osteoarthritis typically affects older patients, in some cases it can affect younger, active patients causing significant pain and disability.
The role of glenohumeral chondral lesions in the natural history of shoulder arthritis has not been well established, as most cartilaginous lesions of the glenohumeral joint are found incidentally and are well tolerated in young individuals. The diagnosis and treatment of symptomatic chondral shoulder lesions in young and active middle-aged patients is challenging and lacks a clear diagnostic algorithm. Often times the diagnosis is only reached when all other shoulder pathologies and causes of glenohumeral pain have been considered. There are multiple sources of shoulder pain which must be considered in addition to cartilage lesions including labral pathology, biceps tenosynovitis, rotator cuff pathology, infection, and loose bodies.
Chondral lesions of the glenohumeral joint are not uncommon and have been found incidentally in 4.5–8.5% up to 17% of middle-aged patients with full-thickness rotator cuff tears during diagnostic arthroscopy. Cartilage injuries may occur on the humeral head, glenoid, or both. These lesions often result after traumatic injury, arthroscopic surgery, osteochondritis dissecans, infection, chondrolysis, or avascular necrosis. Most commonly, however, lesions may result as an early manifestation of degenerative arthritis. Chondral lesions have been noted in previous reports rang- ing from minor cartilage lesions such as fraying or thinning to complete cartilage loss. One of the main difficulties in managing these chondral lesions is determining if they are a pain generator as even large lesions can be well tolerated. In addition, treatment is challenging as shoulder arthroplasty is not ideal in a younger age group despite its pain relief and restoration of function.
Initial treatment for symptomatic chondral lesions consists of nonoperative management with activity modification, steroid injections, and physical therapy. If these therapies fail, there are a limited number of surgical options available. Previous studies have investigated the long-term outcomes of total shoulder arthroplasty and noted good clinical success, particularly older patient with glenohumeral degenerative disease and an intact rotator cuff—in one series by Torchia pain relief was achieved in 83% and implant survival was 93% after 10 years. In young and middle-aged patients, clinical success has been mixed. Sperling in a recent series of 33 patients with a mean age of 46 years at the time of TSA, reported a 38% incidence of glenoid component failure requiring revision surgery. Non-arthroplasty treatment strategies for glenohumeral arthritis have been devised in effort to postpone the need for total shoulder arthroplasty and avoid the incidence of early glenoid loosening—these techniques are integral to the treatment of younger patients with painful chondral lesions.
In place of arthroplasty, arthroscopic treatments have been used including debridement, chondroplasty, capsular release, biceps tenotomy or tenodesis, and subacromial decompression, and more recently reparative techniques including microfracture, autologous chondrocyte implantation, or osteochondral grafting. However, the outcomes of these treatments are highly variable in regards to pain relief and restoration of function. The purpose of this paper is to examine the evaluation and management of glenohumeral chondral lesions and discuss the surgical treatment options for young and middle-aged patients.