Consider biologic resurfacing

Bone-preservation is important for this patient population with shoulder osteoarthritis.

Issue: May 2008

ByLeesa M. Galatz, MD

Leesa M. Galatz, MD
Leesa M. Galatz

Total shoulder arthroplasty has produced excellent results for a number of indications, especially osteoarthritis. However, glenoid longevity is a significant concern in the younger patient.

Glenoid complications including wear, radiolucent lines and loosening are among the most common complications after shoulder arthroplasty. These concerns are magnified in an individual with longer life expectancy and increased physical demands.

We are seeing an increasing number of early cases of osteoarthritis (OA) in the shoulder. It is not clear whether this is due to an increasing incidence or improved recognition and diagnosis. Younger individuals who present with OA are often involved in vocational or recreational activity that includes weightlifting or heavy repetitive activity. Arthritis can also develop as a complication of arthroscopic procedures. Therefore, the young patient with early OA is becoming a common topic of discussion among shoulder surgeons.

Options

What are our options for a 50-year-old male with glenohumeral arthritis after a thermal capsular shrinkage? Arthroscopy with debridement is an option. This option is better indicated in a shoulder with some maintenance of joint space. Its utility is decreased in late arthritis with “bone on bone” or complete loss of joint space. In later OA cases, arthroplasty is a more reliable operation for predictable pain relief.

There are many alternatives in terms of joint resurfacing. Hemiarthroplasty, total shoulder replacement and humeral head replacement with biologic resurfacing have all been reported with good results. Glenoid longevity should be considered when treating a younger individual. Radiolucent lines have been reported in multiple series, and are seen in both early and late follow up. Not all lucent lines are clinically significant, however. Loosening of clinical significance can shorten survival of an arthroplasty. Therefore, since our goal is to preserve lifestyle and the vocational demands in a young person; alternatives to glenoid implantation deserve some consideration.

Resurfacing history

The earliest reference to glenoid resurfacing was in 1942 when it was used for a proximal humerus fractures. It was reported in 1990 for a resection arthroplasty. Burkhead and Hutton really brought this to our attention in 1995 in the context of a young person with OA. Burkhead reported in 2003 on using an Achilles tendon on both the acromion and the glenoid for rotator cuff arthropathy. Although he pioneered biologic resurfacing for this indication, several other authors have since reported on it using multiple different tissues for an interposition arthroplasty specifically for this purpose.

One technique involves separating the anterior capsule from the deep surface of the subscapularis and resurfacing the glenoid with the anterior capsule. Other techniques utilize Achilles tendon allograft to resurface the glenoid and even the undersurface of the acromion. Another popular technique uses allograft knee meniscus. This tissue is designed for weightbearing, and so seems theoretically to be a logical choice. Iliotibial band has also been described.

Concerns surrounding use of an interpositional arthroplasty include resorption, long-term durability, and glenoid wear. Infection and host reaction are also concerning, but infrequent.

Technique

My preferred tissue for interpositional arthroplasty is knee meniscus. It is load-bearing tissue, wedge shaped, and can be sized to circumscribe the glenoid. A lateral meniscus is particularly suitable because it is a little smaller in size than a medial meniscus, but greater in thickness. A discoid meniscus is ideal for glenoid resurfacing. Thus far, immune reactions have not been reported with this tissue.

The glenoid face should be prepared before securing the graft. Some surgeons recommend reaming the glenoid; others prefer to burr the outer rim. Regardless, the concept is to prepare a bleeding bone bed to optimized graft host healing.

The technique for glenoid resurfacing with meniscus has been termed “the parachute technique” by Wirth. Bone tunnels and/or anchors are placed circumferentially around the glenoid. The anchors are loaded with #2 nonabsorbable sutures or the suture is passed through the bone tunnels. The suture is then passed through the donor tissue in circular fashion to attach the tissue to the bone. Each suture limb should be clamped separately for identification and laid in organized fashion around the incision until it is time to tie. All sutures are passed before tying. The graft is then passed down the sutures (like a parachute!) and the sutures are tied.

The technique is technically demanding. Performed correctly, it actually takes longer to do a resurfacing than it does to put in a glenoid component. It is best for concentric glenoids, because the graft will not center on a posteriorly subluxed humeral head. A patient with posterior glenoid wear arguably may be a contraindication for a successful meniscal allograft.

Initially most patients have well-maintained joint space on postoperative radiographs. However, graft fixation and healing are concerns. Many patients with excellent initial postoperative joint space with time begin to demonstrate narrowing and sometimes complete loss of joint space. This may be due to wear of the graft, failure of healing or a problem with graft fixation.

A recent paper by Krishnan reported glenoid erosion of 7 mm. This is concerning. The erosion seemed to stabilize after 3 to 5 years. The authors reported a high rate of complications in addition to the glenoid erosion. The average postoperative American Shoulder and Elbow Surgeons (ASES) score was 91. Overall, the authors are strong proponents of this technique and in their hands; this procedure leads to good results.

Other authors have not reported such optimistic findings. Specifically, Warner and Higgins recently presented far more unfavorable results at the closed meeting of the American Shoulder and Elbow Surgeons in 2007 and at the 2008 American Academy of Orthopedic Surgeons meeting. They found this procedure to be much less reliable for pain relief and had a high revision rate.

I believe there are distinct advantages to avoiding a prosthetic glenoid component in a very young patient. Chronologic and physiologic age should be considered. In a very young, active patient, soft tissue interposition should be considered as an alternative to a prosthetic component. The risks of soft tissue interposition as well as the likelihood of pain relief should be weighed against the risk of glenoid failure in each individual patient.

Preserving glenoid bone stock is important in these patients, so you may want to consider biologic glenoid resurfacing.

For more information:

Leesa M. Galatz, MD, can be reached at Washington University Orthopedics, One Barnes-Jewish Hospital Plaza, Suite 11300 ,West Pavilion, Saint Louis, MO 63110; 314-747-2813; e-mail: galatzl@wudosis.wustl.edu.

References:

Burkhead WZ, Hutton KS. Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder. J Shoulder Elbow Surg. 1995;4(4):263-270

Galatz LM. Controversies in shoulder and elbow arthroplasty. 50 year-old male with OA: HHR with biologic resurfacing. Presented at Orthopedics Today Hawaii 2008. Jan. 13-16, 2008. Lahaina, Maui, Hawaii.

Krishnan SG, Reineck JR, Nowinski RJ, et al. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis. Surgical technique. J Bone Joint Surg (Am). 2008;90 Suppl 2:9-19.